GW1--04094_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:
M t Yt A-1 14.WATER ZONES
FROM TO DESCRIPTION
ft. R.
Well Contractor Name
It. It.
2 A
15.OUTER CASING(for multi-cased wells i OR LINER(if ap livable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. / ft. ft. %S'in. 0VCr
16.INNER CASING OR TUBING(geothermal closed-loop) j
Company Nam //,/(' FROM 7O DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: SA r�4I I ft. f` in.
List all applicable nett construction permits(i.e.County,State, Variance,etc.) ft ft. in.
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER Si-OT SIZE THICKNESS MATERIAL
Water Supply Well:
f[. ft_ in.
CI Agricultural ❑MunicipalIPublic
ft. R. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) _
❑Industrial/Commercial ❑residential Water Supply(shared) IL GROUT
FROM TO MATERIAL EMP
LACEMENT METHOD&AMOUNT
❑Irrigation / R. JO R. &mey ! / (j)(e-!
Non-Water Supply Well: R. ft.
❑Monitoring ❑Recovery
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier rt. ft.
❑Aquifer Test ❑StormwaterDrainage R ft
0 Experimental Technology DSubsidence Control 20.DRILLING LOG(attach additional sheets If necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness.soil/rock t)pe,graln size,eta.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R, r' ft. `J t�t-f 1� (-3-/,f f
si
4.Date Well(s)Completed:& Well ID# �A R_ a-7 it ieite-/ J//e
5a.Well Location: �l�'7R, aOSIL / -��,/L,J6
(2� 0 I of leis' LCC «. R.
Facility/Owner Name 1 Facility ID#(if applicable) ft ft ,1.j: 3 f3�c e v r KI, MCu7on AX: ft. • r
r
Physical Address,City,and Zip 21.REMARKS 1'_ 1 2 2024
MC POtt)171/
County Parcel Identification No.(PIN) BAC"1;kj'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce '!cation•
(if well field,one latilong is sufficient). ( ,
5 'f0175� N ES a ' 0ar3ioci W 1/2—c� -, l�f
Sutra ofCcrtified Well onttactor `� Date
6.Is(are)the well(s): Permanent or OTemporary By si ring this form.1 hereby certify that the well(s)nos(were)constructed in accordance
with SA A'CAC 02C.0100 or 1 SA.VCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair roan existing well: ❑Yes or 7 No copy Of this record has been provided to the nett owner.
lfthis is a repair,fill out known well construction information and a plant the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or 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 wells ONLY with the samesa" construction,you can
lmit tow form. SUBMITTAL 1NSTUCTIONS
9. lVTotal well depth below land surface: (iJ ( )
ft, 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells lbt all depths ifdilli'rent(example-3(t6211/0',an/d @100') construction to the following:
10.Static water level below top of casing: lL'�\ (ft.) Division of Water Quality,Information Processing Unit,
( 1617 Mail Service Center,Raleigh,NC 2 7 699-1 611
lJ rater level is above casing.use"//" i
11.Borehole diameter: �/ /ST' (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: I�C i16) I'/ construction to the following:
(i.e.muter.rotary,cable;direct push,etc.) 11 Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
/(91 G 24c.For Water Supple&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
completion of well construction to the county health department of the county
1 13b.Disinfection type: Amount: where constructed.
Goren GR'-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

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