GW1--03659_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:
Mfk r K A-1 1 en 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
0 n lc A ft. ft,
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER Of applicable)
FROM TO DIAMETER _ THICKNESS MATERIAL Clearwater Well Drilling Inc. ( ft -j`-) IL �G,i` in. p,,, c _
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS _ MATERIAL
2,Well Construction Permit#: 4'� �/r� — )1 �_.. ft. ft. ia.
List all applicable cell construction permits(i.e.Canary.,State,Variance.etc.) —R. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipalPublic ft. ft. in,
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑lndustriallCommercial 0Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL
� EMPLACEMENT METHOD&AMOUNT
�on-Waion Supply Well: R 2L0 R. ( t t-(,Y�t f t I t VA'Ci
ft. ft
❑Monitoring ❑Recovery
injection Well: ft. It,
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
__�
❑Aquifer Storage and Recovery OSalinity Barrier fl ft
❑Aquifer Test ❑Stormwater Drainage
ft_ ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/reek t pe,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ` ft' —7 ft �:/�'(.1( l� -�-- —
t-&O-ay ;-,� ft. 1Jo (Iti-0..A...LIL,
4.Date Well(s)Completed: Well ID#
ft. ft.
5a•Well Location: ft, II-
{ _tt , ,� \y C1 1� JCL �`
c
rt. ft'
Facility/Owner Name Facility ID#(if applicable)
qc U >t>i Pei) " cF ¶ - k rc; -t- ft �t�'rc LA./ir
t U V— t' a, ft. s-A
Physical Address,City,and Zip 21.REMARKS l .1v 4t4 ( �
County Parcel identification No.(PIN) J U N 1
8 2024
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 .C rtifieation: 1
(if well field,one iatllong is sufficient) lLWN2, W 1 !Ji; L . i D'tf Ct Cis cJ d ;4
Sfgna of Certified Well C ntmct�-- Date
6.Is(are)the well(s):)permanent or OTemporary By signing this form.I hereby certijj'that the nell(s)sins(Were)constructed in accordance
with iSA NCAC 02C-0100 or 15.1 NCAC 02C.0200 Well Constriction Standards and that a
7.Is this a repair to an existing well: Oyes or t No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information Al explain the nature(Ole
repair under k21 remarks section or on the back 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-eater supple wells ONLY silk the sane construction,you can
suhn,ir one form_
iNSTUCTiONS
9.Total well depth below land surface:
} LJ(` )7') (ft.) 1Aa_ For All Wells: Submit this form within 30 days of completion of well
For multiple welLs list all depths ijdifferent(itsan,plc-3@n,200•and, too) construction to the following:
10.Static water level below top of casing: —^ (ft.) Division of Water Quality,Information Processing Unit,
if:rater level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
l
11.Borehole diameter: � / (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: \C—C'\(1- -1/4\-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: 1636 Mail Service Centt r,Raleigh,NC 2 7699-1 63 6
)
(6-1 24c.For Water Supply&injection 3%ells: 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
13b.Disinfectiontype: 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 Qusli.y Revised Jan.2013