GW1--03205_Well Construction - GW1_20240524

WELL(:LIMNS CKUL 1 IUIV KLl-UM./ For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
M CO Y KAl 1 t,'1 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft, ft.
6'7 ? A ft. ft.
[mi15.OUTER CASING(for multi-cased wells)O_R LINER(if applicable)
Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ‘ ft. r'J- �- ft. , '� .in. t J�
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) l J
1• /''` }q�I�(� G FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: \iJ C.1 t.1.1D 4--
1 S' et. ft. is;‘-.
--
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
❑Agricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) 1:2esidential Water Supply(single) ft. ft
' 1n.
0Industrial/Commercial ❑Residential Water Supply(shared) IR.GROUT
£ROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lm ation 1 n. ff ' ( 1 d
Non Water Supply Well: / ��,r i` ��� 4 C
R. ft.
❑Monitoring °Recovery
Injection Well: It. ft.
°Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
it, ft.
❑Aquifer Test ❑StormwaterDrainage ft. H.
❑Experimental Technology °Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardaesa,soiurvckh pc,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I n, 5 Lf- It. , Yl£ + �Ir'1 1l t-
Orr
4.Date Well(s)Completed: Well[D# 4- f. , I I ft. �Cl/�.L� t.ri
514
s i nr.-
a.Well Location:Ca ft. J'� R. V �C/�i
Jl� R. _O st qt-o_nqc
O I--- 1c.-1 ( A,i e.Ic r- R.
Facility/Owner Name Facility ID4(if applicable) it ft. -t.. v
14 ? hcn +- I ant, � r V �1- � ft. . ft. inty 2
Ph ical Address,City,and ip J 1 21.REMARKS 404
Do i:;•
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.C rtifcation•
(if well field,one Uctllong is sufficient) r y (� ,
35 S tlT (7 t1 .-15 N S `.P 1 J• LP C1 W ii k, w—C _ 5 .-3 J{7
Signa are of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or DTemporary By sig ring this fi,mr,I hereby cert ,that the;tells)was(Were)constructed in accordance
\ with 41 NCAC 02C.0100 or 1S.4,VCAC 02C.0200 Well Cnnstruetion Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1No copy of this record has been provided to the well owner,
if this is a repair,fill out known well construction information and ',plain 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 sante construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: V!Lt'�' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple u-elLs hit all depths if different(example-3(ft200'and 2(tt‘,100') construction to the following:
10.Static water level below top of casing: LO U (ft.) Division of Water Quality,Information Processing Unit,
1l water level is above casing.use"1'" 1 , 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 11' I J (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
�p above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 10
C 1 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: n 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
'C, 24c.For Water Supply&injection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: , , the address(es) above, also submit one copy of this form within 30 days of
I3b Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form OW-i North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013