GW1--04102_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This tbrm can be used forsingle or multiple wells
I.Well Contractor Information:
MarK A l lc-fl l4,WATi(R ZONES
, FROM TO DESCRIPTION
Well Contractor Name ft, ft.
32 W A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(tar maid-cased wells)OR WNW Of app le)
_PROM TO DIAMETER - THICKNESS MATERIAL
Clearwater Well Drilling Inc. j ft. i u, ft* c,'\V In. ,ixic
Company Name 0 !, I6.INNER CASING OR TUBING ••-••noel ciwed-{tap)
�} I I ly 'M i�_ t AMETEK THICKNESS MATERIAL
2.Welt Construction Permit a: ft. ft. in.
List all applicable well construction permits(Le Comm State,Variance.etc) - R. R. ht.
3.Well Use(check well use): - SCRE
Water Supply Well: t_intoM 1111M111111111111113t s SLOT SIZE • THICKNESS MATERIAL
ft. ft. !n.
DAgricultutai ©Mtmicipal/Public ,_
❑Geothermal(Heating/Cooling Supply) )esidential Water Supply(single) Fr. R. In.
❑industrial/Commereial DR\\esidential Water Supply(shared) tg.GROUT
IMQM T!O� /�MATTERRIAL E FI AC(MT F M 4t-THOD a AgIOUNT
❑loigatlon i ft'
t Y) ft' 1 0.I 1 e I t r'I (e cl
Non-Water Supply Well:
°Monitoring °Recovery R ft `—
injection Well: ft• ft-
OAquifer Recharge °Groundwater Remediation ill 8ANDWGRAVKL PACK(It applkablp)
i:itost TO MATCiIAL ', £MPLACFatSN?METHOD
DAquiftr Storage and Recovery °Salinity Barrier ft, ft.
DAquitier Test ❑Stormwater Drainage
ft. ft.
°Experimental Technology ❑Subsidence Control
'S.DRILLING LOG(attach additleaal sheets If oeeessery)
°Geothermal(Closed Loop) °Tracer FROM TO De9CRIPTION(nbr,binlitesjtelitna gpo,yrata ate,tic.)
Dt3eothermat(Heating/Cooling Return) ❑tJttter(explain under I{ll Remarks) (I [IAfit• `a air i-
4.Date Well(s)Completed: Well IN )o l ft. '1 IL Gras
I7(r n. I11 L exe,UV- 1
5a.Well Location: zn &-‘\tle.rs Ti �� 0C
ft. /'�(r
ft. R. u
Facility/OwnerName Facility BM(if applicable)
ft. IL F 7:-a 011
Pyi ra j- Hope, an . — ft f 1 2 2024
Physical Address.City,and Zip I.REMARKS
q.en cCersor� >.
County Parcel identification No.(PIN)
pVrCsllG.:
5b.Latitude sad Langitade in degrees/minutes/seconds or decimal degrees:
floe:
(if well field,one 1st/long is sufficient)
-35' 35' LQ5 SG N )' y-I ' Li D, C-) W (2).4,1 .�\' '� to - 10-
Si o Certified Well Co ator \_r Date
6.Is(are)the welt(s): ermenent or ClTetnporasy By sight this Jonn,I hereby reed)'that the neell(s)nos(were)mnsnurnsd in accordance
with 15A CAC 02C.0100 or iSA NCAC 02C.0200 Well Constn,ction Standards and that a
7.1s this a repair to an existing well: DYes or , No copy ofthl,rerand her been provided to the well owner.
I f this is a repair,fill our known+well construction information and explain the nature qj the
repair under 1i21 remarks section or on the back of this form. 23,Site diagram or additional well details:
You may use the back of this page to provide additional well silt details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For mu/lip/e injection or non-npter supply wells ONLY With the same construction,you can
submit one Mat ' SUBMITTAL IiNS UCTIONS
9.Total well depth below land surface: Ca 1 .3 (it) leas For All Welk: Submit this form within 30 days of completion of well
Far multiple wells Oct all depths Ifd(fferent(example-3(4)200'and 2(a)100') construction to the following
10.Static water level below top of casing: LP C) (ft.) Division of Water Quality,Information Processing Unit,
if water Jere/is ohms'caring,use'•+.• 1617 Mali Service Center,Raleigh,NC 276991617
11.Borehole diameter: J 5 (in.) 24b.For injection Wells: In addition to sending the form to the address in 24a
t� above, also submit a copy of this form within 30 days of completion of well
12.Weil construction method: S CA.a k construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Centro!Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
c �13a.Yield(Rpm) Method of test:
(;� 24e,For Water Supnly&lniccliotn Wells: 1p addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina department of Environment and Natural Rcsoracces—Division of Water Quality Revised Jan.2013

Weil WOW -� tediraffigadegt
Owner: 2L
New wet -----��-------
.< "F" L
referenced well was grouted in appearance In accordance
I hereby certify that the above
with
all county Well rules.
weil :
Dat
construed=
Total Depth:_1225--- T le
Casing Thidcneas:
`'-
Casing Deptie_WL—.
Drivie Shoe:
GPM: D