GW1--05859_Well Construction - GW1_20241001

WELL CONS1'RVcTION REcoRD for Internal use ONLY!
This form can be used for single or multiple wells
1.Well Contractor information:
Mari( .k tiTROM 1 i 14,WATER ZONES TO DESCRIPTION
Well Colonic/or Name ft, R.
31,?4 "A ft. R.
NC Well Contractor Certification Number �B PUTZR CASING(lee dN-cijR4 Belk) RT LINRR(if �I
Paoom xo otwntexgn_ Terckx6ss4�{6
Clearwater Well Driliing Inca ) �. �-� ".� �;�`�, ,n. !ff Uh
Company Name 16.RQ4ERCAl11i1Q OR=INC(geothermal elassd40ap) s,t
A 1 , PROM TO Di*MgIYP _ T KXNESS MATSALtt.
2.Well Caaatruction Permit 0: s. Is. is
Lisi o!!applicable well construction permits(i.e.County.State,Vnrkmc'e,etc.) _
n. ft. in. —
3.Well Use(check well use): I7,SCR: -- —
Water Supply Well: i ritOM TO DIAMETER SLOTS(ZE TRICKNESS MATERIAL
DAgricuitutal OMunicipal/Public it. i1 ie
Cl Geothermal(Heating/Cooling Supply) Residential Water Supply(single) n' In,
OlndustriaUCommercial 0 esidential Water Supply(shared) J 1T
Olrrigation FF /n k•
MURK TllOD a AlcitnaNT
Non-Water Supply Well: I sr. 11� a, l'Q i
❑Monitoring ORecove ry S. _ it.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/G VIIL PA malkablisl '
ClAqulfcr Storage and Recovery 0Satinity Barrier FROM ><tATEwAL altar Acaaarfiiveyaemou
R, R.
❑Aquifer Test DStonnwater DrainageIL
_—
DExperimental Technology DSubsidence Control ft.
DOeotherttaal(Closed Loop) D)}nett 29.IDIz1I ING I.OG(a additional dusts if mustard
FROM TO DESCRIPTION Lollar,aasditess,I•Wreete qr.trite she.dr.)
OGeothermal(Heating/Cooling Return) DOther(explain under 021 Remarks) �tI it 4-1 h ��+CU f
4.Date Well(s)Completed: a�D ay Well[Da j(r1ft.�I it �( 9. a tt
Se.Well E ocatiola: `^Y! ""F Li
ivj a 4---i; 4[A P I aR R
.. R
Facilily/Otrner Name iDE Of applicable) -�_l ' 1.i s/t
a5 —)-; ft. .
sir [ P_S 1 v� ft /� uc , 0 i beta
Physical Address,City,old Zip loreiv a-1(6
`-1r1 /�///���){)Y' my ///�����, ttt//��� ,i (/�. 2a.itEtHw8x9 ,a
1 —c,( i 1� ly1 v�CI V 11..J.7,rrK,: , ._; ,X
County Parcel identification No.(PIN) DV1 CJ3_v
5b_Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one&sloe ag is sufficient) 22. ,
rCati p
ate
6.is(are)the weu(s): #ertnaaent or OTessporary By skein this form,,I hereby certttyileac the Ire/f(s)Mu(here)constructed in occorOrtnce
with ISA NCAC 02C.01t70 or!SA hte,4C MMMC'.0200 Well Construction Simaderdr and that a
7.is this a repair to an existing well: [Wes or ,l to copy of this record has been provided to the well(Axmree
!f this is a repoir.f!!out knoux well construction Reformation and explain the nature of the
repair under k11 remarks mean or on the bock of this farm. 23,Site diagram or additional Well details;
You may use the back of this page to provide additional well site details or well
B.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injecttoo or non-water supp(v wells ONLY with the same Cwstractioa,you Con
subornonefiats. SUBMITTAL INSTUClIONS
9.Total well depth below land surface: .k)UCD (ft) 24a. For A& Wells: Submit this firm within 30 days of completion of well
For multiply italic list all depths ifdifferent(example-3(a)200'• ,2@i(10') construction to the following:
10.Static water level below top of easing: ,D (R,) Division of Water Quality,Information Processing Unit,
If water less!is above eating,core..+.. r 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. �n i% (ist,) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: roi-Curuf above, also submit a copy of this form within 30 days of completion of well
construction to the following..
(i.e.auger,rotary,table,direct push,sac.)
Division of Water Quality,Underground injection Centro!Program,
FOR WATER SUPPLY 2 WELLS ONLY: ^ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) v Method of test: 2/`' t
24c.
For Water Sm iv&Iniectlon'eid i to addition to sending the form to
address(es)above, also submit one copy of this form within 30 days of
13Y I14s(elletlon type: Antostnt: completion of well construction to the county health department of the county
when constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water
Quality Revised Jan.2013

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