GW1--03672_Well Construction - GW1_20240618

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
us
I.Well Contractor information: i
N1 rk r K Al i a) 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3-12- 4; A ft. ft.
NC Welt Contractor Certification Number 15.OUTER CASING(for multi-eased welhLOR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
t(H �. 9151 I �, FROM TO DiAMETE'R THICKNESS MATERIAL
2.Well Construction Permit#: Ll lJ lJ� ft. ft. in.
List all applicable well construction permits(i.e.County,State, Variance.etc.) _
ft. ft. ie.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: ' FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑A rjCUltural ft. ft. in.
g [Municipal/Public
❑Geothermal(Heating/Cooling Supply) GdResidential Water Supply(single) ft. ft. in.
❑Industrial!Commercial DResidential Water Supply(shared) FROM18.GROUT
TO MATERIAL, EMPLACEMENT;• TROD&AMOUNT El Irrigation , ft. .7,
4-' ft CC 1~Jf n
64
Non-Water Supply Well:
❑Monitoring El Recovery ft. ft_
Injection Well: ft. ft.
❑Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology DSubsidence Control
20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION1eolar,hardness•soiUrack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) l ft. (C) rt. �(t r'iI 4- ,'- ,1/
'' nn o at�� ` y►i
4.Date Wells)Completed: Well iD# W G ft• al a � ,(1 {
5a.Well Location: rt. c�/3 ft.
�`�� tc
A 1e'n r4f ,� ft. ft. �- ,
Facility/Owner iJame Facility iD#(if applicable)
33 1--1 c per Co ft. ft. JUN 1 -8 2024
Physical Address,City,
F Zip
l 21.REMARKS
l �`"'����\ )�r� d — "lit Niel ,Y'r.•�R:-,LJ
Dwc4 304
C�my Parcel Identification No.(PIN) A
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 a teatioa- 4
(if well field,one tar/long is sufficient •
)
•t %
.35 �, �Q ,"I11 A N 3 n0 i-} "1
/ Signiture fCertified Well Contra or Date
6.Is(are)the well(s); ! Permanent or ❑Temporary
By signin this loan,I hereby cerpt that the swill's)war(were)constructed in accordance
nub 15A CAC 02C.0100 or 15A NCAC'12C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ;'moo copy of rhi. record line been provided to the well toner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#2t 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-water supplt•wells ONLY with the same construction,you can
ubmit 0111710,m ) SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: l.Y t ✓ (ft.) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferem(eramrle-3(ri 2110•and2000) construction to the following:
10.Static water level below top of casing: U)C• (ft.) Division of Water Quality,Information Processing Unit,
if toter level is above cueing.use••+- t I 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: w J (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this farm within 30 days of completion of well
r
12.Well construction method: U 11 C-l \./ construction to the following:
(i auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY!YELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
`C
13a.Yield(gpm) I J Method of test: (2% 1 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 OW-I North Carolina Department of Environment and Natural Resources--Division of Water Quality Revised Jan.2013

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