GW1--06091_Well Construction - GW1_20230921

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form cantle used for single or multiple wells
1.Well Contractor information: (fin�`
jr)3 / P IC/��1 1\io, /J 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name,( / ft. ft.
'�ikt.�'
. i e�2`�1 .74. ft. ft. I
i
NC Welt Contractor Certification Number 15.OUTER CASING(for mold-caged wells)OR DYER Of op Usable)
FROM TO DIAMETER ICKNESS MATERIAL
Clearwater Well Drilling inc. ( B. 30 ft. ko,k in. pvc
Company Name 16.INNER CASING OR TUBING(geothermal elosed-400p)
(1�_pt�Oh� _an FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 1 ff��� a ft. in.
List all applicable well construction permits(i.e.County.State.Variance.etc.)
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgriculttual °Municipal/Public ft. ft. In
°Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. It. In.
°Industrial/Commercial °Residential Water Supply(shared) 18•GROUT I
FROM TO•(� /M ATgERRIA�Ly q-�,EMPLACEMENT METHOD&AMOUNT
°Irrigation ft.
p �J n. l X.t 1 �l.t 1 rot IL (,`•
Non-Water Supply Well: t i
°Monitoring °Recovery R' D' I
Injection Well: ft. ft.
°Aquifer Recharge °Groundwater Remediation 19 SAND/GRAVEL PACK Of applicable) 1
ClAquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
ft R. I'
°Aquifer Test OStotmwaterDrainage R, It.
°Experimental Technology °Subsidence Control
20.DRILLING LOG(attach additional sheets If decestary)
°Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION cobs,hardness.sal0mcktypa[rainstre,ete)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) k R Q p 2 It/
}-dt
4.Date Well(s)Completed: Well ID# � f ' ft• r l'x�/l t�
Sn.Well Location: R ft eu Ck
) t r1( Phoxr ft.rt. n. r �1-�—
Facilityfam Name Facility IDO(if applicable) l 9 ..a. f r-
415 Mi-n • �-Q'(5 rt. rrt. � .r a��..
\)C
Physical Address,City,
and ztp IL
Pr REMARICS
SFp � 1 7023
l 11 Mirt SO'� I 7',-^b..14 r. ij t'A
County Parcel Identification No.(PIN) [NV'k,,;v-.L,
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field.tine tat/long is sufficient) 22.Ceftlfieati
35 ' IG'04.3o N SA' Lfl t 1 O. 13 W ,..................-- 7-S-a 3
Signature. Certified Well Contractor Date
6.Is(are)the well(s):'termanent or °Temporary By signing this form.I hereby mrlt&y that the wells)kW(were)constructed in accordance
with 15A NCAC 02C.0I00 or ISA NCAC 02C.0200 'ell Construction Standards and that a
7.Is this a repair to an existing well: (Wes or t;itklo copy of this record has been provided to the twit on •.
If this is a repair.Jill out known well construction Information and avian the nature of the i
repair under#2/remaris section or on the back of thisform. 23.Site diagram or additional well details:
You may use the back of this page tot provide:dditional well site details or well
8.Number of wells constructed: construction details. You may also attach additi'nal pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction.you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 5- (ft.) 24a. For MI Wells: Submit this form with' 30 days of completion of well
For multiple wells list all depths ifdij[erent(ample-3@200'and 213100') construction to the following: 1
i
10.Static water level below top of casing: (fL) Division of Water Quality,Info tion Processing Unit,
ljwnter level is above casing,use"+"1 1617 Mail Service Center,Ralei h,NC 27699-1617
1/�
11.Borehole diameter, l!b a (In.) 24b.For infection Wells: in addition to sen ng the form to the address in 24a
above,also submit a copy of this fomv with' 30 days of completion of well
12.Weil construction method: Mandl construction to the following: j
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground injection Control Program,
FOR WATER SUPPLY
�WELLS ONLY: 1636 Mall Service Center,'Ralei b,NC 27699-1636
13a.Yield(gpm) y1 Method of test: RfCt 24e.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above,also submit onelcopy f this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
I '
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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Waft Der iiputdtfm
\AD' p YY _ New wren:
wrest 415 �l�. tvey� ",
B OSS- c9093 - CD-11
'herebyreferenced well vas grouted inappearance in d vat
all calmtyWel ram.
well,d.,-TOSh PA S Signed:
certificaka#: 431—A _ Dam r
Condor: (Ant
Total ne tt,S'
Diameter: l 9'k%
Height
Drive ewe:
GPM: CS -