GW1--04938_Well Construction - GW1_20240816

W LG CONS1,'RUCTION RECORD 1rr Internal the ONLY:
This form can be used for single or multiple wells
I.Welt Contractor Information:
N1l�Y K Mien 141 WAThRZON $
6AOM TO DESCRIPTRIN
Well Coatroom Name ft ft.
3 Z?. A _ It a.
NC Well Contractor CeetFfieatiori Number A&OU1 R Cd.9ING Or aitl.e*,g 4 weal OR LINER Of apgil¢tbte)
Clearwater Well Drilling Inc. FROM ft. 4 n LQ gl x TRIMNESS MATERIAL
1 r �
Company Name CS
/1 �71 If�!(�1{ Ali.INNER C,µtINo QR TURINC(geothermal dotal-lay) mil'.
\J -J L_02.1 - I Li i I FROM TO DMMtiTIR Tom MATERIAL 2.Well Cbnstrucdott Permit it: A. ft. In.
List all applicable well construction permits(i.e.County.Slate,Variance,etc.) .-..
ft. ft. in.
•
3.Well t/le(check well trse): ^
17.SCREEN .
WaterSnpply Wen: IRON _TO DIAMETER 11..OTEIgE TittCkNE$s MAYERtAL
°Agricultural L7Nlwticipal/Pablic I. to.
OGeothermal(Heating/Cooling Supply) residential Water Supply(single) _ ft. R. t1e
t
❑Industrial/Commercial QResidential Water Supply(shared) es.GKvirr
❑irrigedoo pROas TO . MATERl6k, ittnel ACSMent Ft1C1(0OD AMOUNT&AMNT
Non-Water Supply we) I n. ,DC ft' (r(':N.',1)t- 111 /.- CI
ElMonitoring ClRecovery ft. R
Injection Well: ft. R.
°Aquifer Recharge °Groundwater Reniediation 19..&ANA)G VEL PA (If atwlkaltlee)
°Aquifer Storage and Recovery °Salinity Barrier rntoiu To MA'c4 oatetwe�a>�trMCTeoD
n. it.
°Aquifer Test ❑Stormwater Drainage
°Experimental Techno ft n'
lo8Y OSubsidcttce Control
0Gcothemtal(Closed Loop) ❑Tracer t pR1jGLiDft3 LOG(�`p�j tiddtrdtaa(alneh it necasarrl
1 TO 1 tICS�RiT�ols lento raedrtrs rlYtaek jrpy:ilia atm no
OQeothermal(Heating/Cooling Return) OOthcr(explain under#21 Remarks) ) ft* 4-1 tt. i
4.Date Well(s)Completed: i'd`r I��Well MN �� 1 (' ,
52.Well Location: 1 C . � 1 (.,� 1 51 la* 5l R ,A l,(
Jt..)I--)n c- 1 LA-Vye.1\e; tii�DDre R. 1DSIL erar�k +�
ft. IL
Facility/Owner Name Facility IDN(if sp liicable)
ft. ft
t53 NIA,K no .e..t Dr. — ,i ft.12,itysic--)a-lI MA
;
crsZD
;p.REMARKS
County Parcel identification No.(PIN) ,
Sb.Latitude sad Longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one eong is sufficient t rrNticatiaia:
'n
Zi 04.15 N .9r 31. Zci Cie w ; G 1 I t `3 I D
s .. o Certified Weil Contractor Date
6.Is(are)the well(s):Nternmaent or OTeeoporary
By signing this form,I hereby cerv),that the Neil(r)wen(!tare)constructed in ac ace
wit!.15A NCAC 02C.0100 or iSA NCAC t ilC.0100 Wall Cbitstnretion Sander&and that a
7.Is this a repair to an existing well: °Yes or kNo copy ofthit record has been provided to Use well ouster.
If this is a repair,fill out known well nunstruetlwt MI'r_notion and erploin the nature attire
repair ender n21 re suvk.,sect)an 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 site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-nrmer supply wells ONLY with the same cotrstrectow,you can
submit one form. SI)BMYITAL INSTUCTIONS
_
9.Total well depth below land surface: �f.t (ft.) 24a. For Al Wells: Submit this Sam within 30 days of completion of well
For multiple netts list all depths If different(example-30
200'and 2 I1)(Yj ' ' construction to the following:
10.Static water level below tap of casing: I <S 0 (ft.) Division of Water Quality,Information Processing Unit,
If fluter keel is above coring,use.-+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11,Borehole diameter: (9 I On.) 24b.For inIettiop Wells: In addition to sending the form to the address in 24s
4 Y above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: I' L)fO / construction to the following.
(i.e.auger,rotary,rattle,detect push,etc.)
Division of Water Quality,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service COMM Raleigh,NC 27699-1636
13a.Yield(gum) c., Method of test Rici 24c.Por Water Supply&injection Wei: In addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
136.IMslnfbctiort type; Amottat;-
where constructed.
Form OW-i Noah Carolina Department of Environment and Natural Resources-Division of Water
Quality Revised Jim.2013

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