GW1--03658_Well Construction - GW1_20240618

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mart/ !J( u i 1.et l 14.WATER ZONES
T� FROM TO DESCRIPTION
Well Contractor Name ft. ft.
02-.J lc A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap able)
FROM TO DIAMETER THICKNESS I MATERIAL
Clearwater Well Drilling Inc. k It. \'C t in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
1 .
2.Well Construction Permit II: E .D3/,D - U 1 4 FROM TO
ocl R. ft. DIAMETER THICKNESS MATERIALin.
List all applicable well construction permits(i.e.County,State,Variance,etc.) -
ft. k. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMu nicipaiPublic
❑Geothermal(Heating/Cooling Supply) )4Residential Water Supply(single) ft. ft. In.
❑lndustriallCommercial °Residential Water Supply(shared) 18.CROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
obligation
ri 4 Watteer Supply Well: l G ft- CP1�f1Q} i1(li bLa
ft. IL
❑Monitoring ❑Recovery -
Injection Well: k. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANWGRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Bahia ft. R
❑Aquifer Test ❑Stonnwater Drainage
ft. IL
❑Experimental Technology OSubsidence Control
29.DRILLING LOG(attach additional sheets If accessary)
OGeothetmal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness.soiVrock type,grain sire,tic.)
OGeothennal(Heating/Cooling Return) ❑Other(explain under 021 Remarks) 1 k- , �O�',ft. Y2 .-4-- cv y
4.Date Wells)Co �a ted:5- -a Well(Mt1 LAW`�, c , i 1 .
5a.Weil Location: C hly,G u ),'1e-r" 1-xo WAO 41D1 ft. CMAJIU
Facility/Owner Name Facility IDS(if applicable) f6 ft. ific
` L.
15-3 N;Lei C- a..{) Pc1 . Oki F-of-t- viC.- ft. ft. JUN 1 8 2024
Physical Address,City,and tip 21.REMARKS
11445 ltn.at 1
Ivc7o we ll r of,g,--1. utt
Ac.1
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification'
(if well field,one tat/long is sufficient)
' k1-11401 N gig' Is 4 5u 3s W \\ of'ivied �'��t 5-a3-a`l
Signalise c Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this fore,I herein'certhjj that the melll(s,nos(werel constructed in accordance
with 1 5A NCAC 02C.0100 or 1 5A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: °Yes or ie copy of this record has been provided to the wail owner,
if this is a repair,fill oat known wall construction information and explain the nature of the
repair under 1121 remarks section or on the back of this jam. 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-xutersupply sells ONLY Kith Hee same constrotelion,you can
uunMrTrA N t_INnsrucTiOC
9.Total well depth below land surface: 5 U5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3(d-200'and 2®l001 construction to the following:
10.Static water level below top of casing: La 0 (fL) Division of Water Quality,Information Processing Unit,
If water level is above caring.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1 i.Borehole diameter: LO lb (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 CY C-r\._( 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
11 ^ C' 24c.For Water Supply&iniection Wells: In addition to sending the form to
13a Yield(gym) �C Method test: ` 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 ctnstnscted.
Fore OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013

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