GW1--04069_Well Construction - GW1_20240712

W FLL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple welts
t.Well Contractor Information: —
,/ —la,WATER ZONES
M a r K M I en f,fROM , TO 016SCRIPTION
ft. ft.
Well Contractor Name —
3 '^ A — n n.
NC Well Contractor Certification Number 15.OUTER CASINO(far meld-card wills)OR LINER Of Spa ca I
'PROM TO D1AMsT5tt THICKNESS MATERIAL
Clearwater Well Drilling Inc. I ft 1(r):3ft. L'i -.• In. ���'
Company Name n/ l' f` [�� _16.INNER CASING OR TUBING(Reotkt:ru s!rioted-loop)
2.Well Construction Permit M: \i x T lJ Tl� —A M ft. ft.TO
DIAMETER
R R I n. THICKNESS MATERIAL
List all applicable well constnictlon permits(i.e.County,State,Variance.etc.) - R ft. in.
3.Well Use(check well use): 4tq,SCREEN — '
Water Supply Well: TO DIAMETER SLOT SIZE THICKNESS MATERIAL ...1
U. ft. In.
°Agricultural ClMunicipal/Pubhc >1. in.
residential a. _—
❑Geothetmat(Heating/Cooling Supply) idential Water Supply(single) _
f3lndustriaUCommercial ❑Residential Water Supply(shared) 1&GROUT
KROM TO MATRRIAL &MrioKIM r(MfrD&AMOVNT
Olnigation _ I '- (..) R. CC IT e i it i'X �.(l/
Non-Water Supply Well:
Ii. ft.
°Monitoring °Recovery --
Injectden Well: ft. ft.
()Aquifer Recharge °Groundwater Remediation IA SAND/GRAVEL PACK(if applcablt)•,-,
IiROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery °Salinity Barrier ft. N.
DAquitbrTest ❑StormwaterDrainage —•- ft. , ft.
❑Experimental Technology ❑Subsidence Control
to i*llIG LOG(attach additional'heels If eteeassry)
❑Geothermal(Closed Loop) °Tracer PROM j To DESCRIPTION Osier.priResysalthoc,r 4v..aratw.eae,ets.)
❑Geothermal(Heating/Cooling Return) ❑tither(explain under 1121 Remarks) / R' /03 D' c�t.tA )7 lot d i/'•J-
4.Date Welds)Completed:1v-1 3 (f Well IDS ) afiLPIL Sr i .
5a.Well Location; NO h. t
NI
Facility/Owner Name acidity ID#(If applicable) It IL 1 ::.b 9rall-1 jr°
„in IThilf \-3 VDLed< ft. a.
,(l..l: V E-�.•
,
1-1 u Da A 7tEDn Dr. r t)kcr) ft. n. ' 1 21n74
Ph( sd try►al Address,City,a f`-)C. it.REMARKS J L
i -1,Xi-orrl ^0e4-4 UPS
County Parcel identification No.(PiN) 1���
5b.Latitude sad Longitude in degreeslndnutes/seconds or decimal degrees: 22.C s:
(if well field,one IaUlong is sufficient)
:35' U-\ (-) .-,-is--1 N , OCt4� . ef w /41Z • % -17 ;.�`f
Si_iaaturepfCeIlfie4 Welt Contractor Date
6.Is(are)the well(s):)ertnanent or ❑Temporary By signing this form,I hereby cerrin'that the wills)Was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC IUC.0200 RWi ConAnnctian Standards and that a
7.la this a repair to an existing well: Dyes or IIo copy of Mr record has been provided to the welt owner.
!(this is a repair,fill out knows[well ctnstntctlon Information and erplotn the nature ry the
repair under till 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
Fer multiple injection or non-ante?supply ssalls ONLY With the same constriction,you can
submit aria farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: at) 24n. for AU Welts: Submit this Norm within 30 days of completion of well
For multiple wells list all depths if different(trample,-30200'and 22(el00') construction to the following:
10.Stade water level below top of rasing: Q (ft) Division of Water Quality,Information Processing Unit.
?(aster level is°prove casing,use"rrt"t 1617 Mali Service Center,Raleigh,NC 27699-1617
C)11.Borehole diameter: ( I U (in.) 241a.For lalection 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: IT)1 -IL{ construction to the following:
(i.e.auger,rotary,cable,direct push,ate.) I
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
PA 24c.Or Water Supply$s 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
13b.Disinfection type: Amount completion of well construction to the county health department of the county
where constructed.
Farm OW-1 North Carolina Department of Envimnment and Natural Resources--Division of Water Quality Revised Jan.2013

iNoii PAW falfdfiront Certification
e „
AddreaKIN-----D-0212 RePair,
3 a
hereby certify that the above referenced well was grouted in appearance in accordance with
all county Well rates_
wen Driner:
AwJLLed
Certificate#: ._ Date Grouted:
Grout
Total Deptit Type:
Casing Typet__p Thicknels:_CC:133—CA—'
Casing Deptild0----
Diameter_1(215--
Drte Sl3oe --
GThI,