GW1--03157_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
M A r K p, ' I 14.WATER ZONES
�^ FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
<3 Z J th A ft. ft.
NC Well Contractor/Certification Number 15.OUTER CASING(for multi-cased weII)R LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. I ft. L.'1 It. it.
tJ fic'r'
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
/� rr (c• FROM TO DIAMETER 7 THICKNESS MATERIAL
2.Well Construction Permit#: k)V�J�cA't Ll,'6t) fL ft. in.
List all applicable well construction permits(i.e. mot}'.State,Variance.etc.)
ft. ft. ht.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS _ MATERIAL
ft. ft. in.
❑Agricultural ❑MunicipaWPublic
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL _..4 EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. R. {
Non-Water Supply Well: AL, ������.(mot j��1 (���
ft. ft.
❑Monitoring DRecovery
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT SIETHOD
DAquifer Storage and Recovery OSalinity Barrier —
R. ft
❑Aquifer Test ❑Stormwater Drainage ft. ft.
['Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM I TO DESCRIPTION(rotor.bardttrs,sail/rock tvpe,grain sIzr,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 ft- I y 1 it. Ci�1 C --- ({I -�1�
4.Date Well(s)Completed: 4- tQ d C Well ID# I 4-14-1trt. 1 (4) 1 I.
recri1 w
(4,--1 ft. t�.ci ft. O re\IiLe
5a.Well Location:
t L(' ft. cos It. (-A-rai )tk� r
.1LUi1.(1 41- ►A,iI\y �:ict C'I'e.c) ft. H.
Facility/Owner Name Facility ID#(if applicable) /�^
t h. MN( 2� (4
PDU l ki C 1,�.Y Q(JI ft. ft.
Physical Address,City,and Zip ) 'y'r*
21.REMARKS
VluillerfLiTi
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Ce.Tiication-
(if well field,one Iaulong is sufficient)
� r�d i N 5a' %t�(�7�'aa W .L `cj,L ti u a� a�I
// Sigra ofCerti We 1 Contractor Date
6.Is(are)the well(s): 6fPermanent or ()Temporary By sign PI;this form,I hereby certifp that the nell(s)nas(Were)constructed in accordance
�/�� with 15,1 NCAC 02C.0100 or ISA NC'AC 0..2C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or f1(No may of this record has been prodded to the well owner.
//'this is a repair.fill nut kr:oart well construction information and explain the nature of the
repair under#21 remarks section or on the hack 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit unefoutn. ( SUBMITTAL INSTUCCIONS
9.Total well depth below land surface: t)L P) (ft.) 24a. For AU Wells: Submit this fount within 30 days of completion of well
For multiple n'eilr list all depths ijdil%aent(ecample-J(t1•200'and 2 d100') construction to the following:
10.Static water level below top of casing: (L•) (ft.) Division of Water Quality,Information Processing Unit,
If ruler letel is above casing.use.. .' t 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (0 16 (in.) 24b.For injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
:
12.Well construction method: ` (-.' (,r 1 construction to the following:
(i.e.sugar,rotary.cable,direct push,etc) Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 C\ 24c.For Water Supply&injection Wells: In addition to sending the form to
Method of test: Ill I 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
13tr.Disinfection type: Amount:
where constructed.
Form OW-1 Nonh Caro!inn Department of Environment and Natural Resources--Division of water Quality Revised Jan.2013

y peer WilLtriodist Cdirdikafl
1 1 � 9P New
r
I certify that
e above referenced well wag grained in appearance in accordance with
all county Weil ram.
Well miner Ail _ _tete
Ce�r�ficae#� ��Ri n
Construction: &nut
05 T �P�Y1eYl��
Total paFtn- .,;�......, Thickness:Casing Depth: c;
Casing Type_c_
`4,, ! :_ . __ O. -
Diameter:
Weight/Thick
Drive shoe: _ _
rat: �u