GW1--03158_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 c r t/ 4' l p Vt Y1 14.WATER ZONES
T� 1 = TO DESCRIPTION
Well Contractor Name ft. ft.
2 c A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap,licable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft. 3 , ft. , 1
1 M.
() )C
Company Name 16.INNER CASING OR TUBING(:eothermat closed-loop)
C. FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: C p lKJ�� Das 1 ft. ft. in.
List all applicable well construction permits(i.e.Count}',State, Variance.etc.)
ft. ft. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: IIIMIIIIIIIKENIMIIIMMOIMI SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
MATERIAL EMPLACEMENT METHOD&AMOUFT
❑Irrigation MEM nl rl� ��, keA
Non-Water Supply Well: Y 1�
ft. ft.
❑Monitoring O Recovery
Injection Well: ft. H.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifap plicable)
FROM TO MATERIAL _ EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
El Experimental Technology ❑Subsidence Control _
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) DTracer FROM TO DESCRIPTION(color,hardness.sui Urock hpe,grain tire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) � it. (:/t,Y t�'-} •.L � r�- •
4.Date Well(s)Completed:4 ht� a Well ID# fc .,�tle�` ih�fit'
y'r ft. -mot ft.
5a.Well Loca' o: CYUdi OtVccL [���
-Vino RI-n-ro
ft. ft. r --
Facility/Owner Name Facility IDS/(if applicable)
Valet 0.e(�:tar YaAls Dr, ft. ft. .. f
�E lure �,�. it. ft. NAAY 1 z: /074
Ph sisal Address,Ci ,and zip
�f 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatllong is sufficient) n. e1lt ICatiO
• 30'
11 hh N %at q 1 9,3" W a( ( -,�ln - `k
Si nature fCertified Well Date
6.Is(are)the well(s): Aermanent or ❑Temporary By signdn. this torn,. I hereby certifi that the t,el(s)wits(mere)constructed in accordance
with I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Xo copy of this record hos been prorided to the well o,:rer.
If this is a repair,fill out known well construction information and explain the nature alike
repair under#2/remarks section or on the back of this fo m. 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 cells ONLY with the same construction,t as can
submit one jot m SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: aJ 3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wetL&list all depths ifdilferent(crumple-Ai:200''and 200001 construction to the following:
10.Static water level below top of casing: U0 (ft.) Division of Water Quality,Information Processing Unit,
7l::star lintel is above racing.the'} 1617 Mail Service Center,Raleigh,NC 27699-1617
ii Qrrlli
l
11.Borehole diameter: ' (in.) 24b. For Injection Wells: in addition to sending the form to the address in 24a
am' above, also submit a copy of this form within 30 days of completion of well
r
12.Well construction method: { U% t ,./ construction to the following:
(i.e.auger.rotary,cable;direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 'nJ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I U Method of test: .,l G 24c.For Water Supply&Injection Wells: In 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 GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013

Wall Maw SelfLamont Coriffkation
Omer: (")•CI I )te N Well:_ _ --
�\ pis . __
PenntL � a3- OdNISCI
I hereby=d y that the above referenced well wM grouted in appearance l acamiance with.
all County Well rum.
Weil Diger, Moir K Ms cn
certificate*: - v,(Lo
Colon: Grout
Tool ; � Tyler—Celle i- .
Casing TYPe: VC, Thir1mess: rn►x P�
( ''
iii` ,
Hetet:
Drive Shoe:
GPM: C'