GW1--04057_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
M(\r K Al 1 f f FROM TO DESCRIPTION
R. ft.
Well Contractor Name
U. ft.
JZ�Si A.
15.OUTER CASING(for multi-cased wells1 OR LINER(if ap livable) t
NC Well Contractor CertiticationNumber FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft. i I`I ft. l.Q'I S' in.� VVC
16.INNER CASING OR TUBING(geothermal closed-loop)
Company Name N — ��l r^ FROM TO
ft. DIAMETER —THICKNESS TMATERIAL
2.Well Construction Permit ft; lt:) tL in.
List all applicable well construction permits(i.e.County,State, Variance.etc.) ft. ft. is
3.Well Use(check well use): 17.SCREEN
FROM ' TO _ DIAMETER SLOT SIZE THICKNESS _MATERIAL
Water Supply Well: ft. rt. in.
❑Agricultural OMunicipal/Public
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) —
glndustrial!Commercia! ❑Residential Water Supply(shared) FROMt8.GROUT TO
MpATERIALL EMPLACEMENT METROD&AMOUNT
❑irrigation I R. G rt. ci n( -e . 1Y ' d
Non-Water Supply Well: ft. ft,
❑Monitoring ❑Recovery --
ft. R.
Injection Well: ----
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Ramer R. rt.
❑Aquifer Test ❑Stormwater Drainage it. ft. —
❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROST TO DESCRIPTlOncolor,hardness.soil/rock type.grain size.etc.) 1
R. fL Wli 4- (.y ' l
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ( 1 �* � � C 11'r
a1_, , I�� it. '9 ft. rani t-C
d.Date Well(s)Completed: V ell ID# U Q ft. r VN1 aCi ft. •1t��(A e
Sit.Well Location: 1 it- 4S rt- . � �.k-)}e
c)---)culr`1iP -I- Q1 r-Li 5-1---e_i 1 "1S ft. R. f . l y+�
Facility/Owner Name Facility MO(if applicable) U. R. t,r L" ' ' L"Z
Qh,9�S Prfxs \ Irl Qd . ITT) ft. ft. iL 1 2 2024
Phy►i al Address City,and Zip U.REMARKS
I O I K Ants •a.. '.- i-rrye,a-t'Jr*
County Parcel identification No.(PIN) V "d 5Gs
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce •fication•
(if welt field,one lat/long is sufficient) c t
9 3'l�
�I�1 14 lg11 N \ rCj 5C( W i ,, / l�
Signal of Certified Well Contractor Date
6.Is(are)the well(s):*Permanent or ❑Temporary By signin this from.I hereby certi/j'that the nell(s)was(were)constructed in accordance
with 154 NCAC 02C.0100 or 15.4,'CAC 02C.02.00 Well Construction Standards and that a
copy o
'I.Is this a repair to an existing well: ❑Yes or No H f this record has been oral ided to the well owner.
If this is a repair,fill oit known well construction information and explain the nature of the 23.Site diagram or additional well details
repair under k1l remarks section ar on the hack of this form.
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 hells ONLY with the sante construction,you can SUBMITTAL INSTUC I IONS_
9.Total well depth below land surface: Li-- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depth+if different(example-30.:200'and 2@l00') construction to the following:
10.Static water level below top of casing: L..Q 0 (ft.) Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
!looter level is abase casing.use"+"`
11.Borehole diameter: �.(L (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
t�
12.Well construction method: 1 CJ\(1J'1 1 construction to the following:
(i.e-queer,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: f 1636 Mail Service Center,Raleigh,NC 27699-1636
1 n 24c.For Water Supply&Injection Wells: In addition to sending the form to
lion Yield(gpm) Method of test: "' the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
Form GW-I North Carolina Department of Environment anti Natural Resources-Division of Water Quality Revised Jan.2013

Wan
WOW Satf.Orout Cardficatken
9}00001L-r 4cy VwSweit__t/
Address: Repair,„
Ihereby
certify that the above referencedwell was gi'utO in appearance
all County Well roles.
well D�ilter• ��oxistruction
certificate*: Dam
Grout
Total Thickness: ---„
11xr
Casing rrype____Ald
Caging Depett --_ Depth:,
Drive
sane: