GW1--04104_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD ',or[memo Use ONLY:
This form can be used forsingle or multiple wells
1.Well Contractor Information:
M a r K Ail I en 14,WATRR
PROM TO DESCRIPTION
Well Contractor Name it
3 z. 'LC A n. n.
NC Welt Contractor Certification Number 15.OUTER CASING(for tnuNt called wens)OR LINE /if appllegbk)
_FROM TO mama:Hot THICKNESS MATERIAL
Clearwater Well Drilling Inc. / n. S-IC it' / /';In. PV t
Company Name _ 16.INNEli CASING t ' TUNING -dltennal daoed-loop)
2.Welt Construction Permit#:
aid Ul o le Ys" r>a
n, TO 1 nit THICKNESS MATERIAL
It. hi.
Lis:all applicable well construction permit?(I.e.County,State, Variance.e/c.)
ft. ft. in.
3.Well Use(check well use):
txbt+t litt To
Water Supply Welt: '_DIAMETER ,sLQTSIZE THICKNESS MATERIAL
°Agricultural L IMunicipaVPublic d. tr to
DOeothennal(Heating/Cooling Supply) residential Water Supply(single) ft. rt. In.
0Industrial/Commercial ❑Residential Water Supply(shared) :$-GROUT
°irrigation TO
MATERIAL, EAtrL CLMF$ M taAlttOVNT
Non-Water Supply Well: _ N/ rti��l R f' j'�� �' Ci
[Monitoring °Recovery R. it
in}tetioa Well: ft. R.
°Aquifer Recharge °Groundwater Repudiation 39.SANQICRAVRI,PACK(If
OAquifbr Storage and Recovery °Salinity Ranier moat To MATERIAL E.NrtwcEMENTMEtHclu
°A uifer Test R'
q ❑5tortnwater Drainage — _
rimental Technology ° ft
❑Ez
Pe ogy ❑Subsidence Control
IlkDRII.uNG LOC(attach additional sheets If geepsory)
°Geothtxma](Closed Loop) °Tracer
PROM _ To DESCRIPTION(calm;OmtgesN sail/00Ilmterala am ate-)
❑Geothermai(Heating/Cooling Return) �y�DOthcr(explain under#21 Remarks) j aL t fti <'/t /1 // „ - „/' 1- -
4.Date Well(s)Completeds�"!/-d) Well tDtl F ram) iL iL (YJn't1 lPUie'L L !
Sa.WNfLocatioa: �Iet. r�qa 'l.L.t�!(,�
,/se,/ Pc �i /ic :i92'� Writ' 'l-Q ifs
at. a
Z�/OWn rName Facility ID#(if applicable) •
ft/ Ai C ll er.f ft. ft. 1, t,. -t'> E
ft. ft. ••Physical Cllx sod Zip
Ir
) SoYJ ?� REMARKS 1 ZOZ4 -
County Parcel identification No.(PIN)
Ifif3a+. �t
:l .f. �*UPI
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees
tG 22,C :cif well field,one laViong is sufficient)
`j
-L��
� _; [rI ' '7 , �� N J �v,L W
Sip/tatureof if3ed Well Contractor '� Date
6.Is(are)the walks): Permanent or OTemporary
By signing this form,!hereby cerM)'that the uell(s)tans(Were)constructed in accordance
with 154 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Constnrcuan Standards and that a
7.Is this a repair to an existing well: (Wes or ,\No
IfMrs Is a copy Bfthls record ht.been provided to the Het/ONtmer.
repair,fill nut known well construction Information and explain the mature id the
repair under 021 remarks section or on the block aphis form. 23,Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
9.Number of wells constructed: construction details. You may also attach additional pages if necessa ,
Far mitlltple injection or non-npter.suppl Kens ONLY flit;the some cansin,ction,you con ry
submitonefirm. SUBMITTAL INSTITC IONS
9.Total well depth below land surface: (_ LI S (ft.) 24a. per AU Welk: Submit this form within 30 days of completion of well
For mrau/ple ue/is list all depths ifdi(ferent(example-3(I0200'and 24/00) construction to the following:
10.Static water level below repot'easing; (1% 0 (f,) Division of Water Quality,Information ProcessingUnit,
If water level it ahme casing,rise"+•' 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: /%}
(ice) 241a.For Injection Weill: In addition to sending the form to the address in 24a
�Qr `/ above, also submit a copy of this form within 30 days of completion of well
12.Well construction method; I'- cgnstruction 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 Mall Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gym) Method of teat: i, 24t.For Water Simply 4 infection Wells; Ip addition to sending the form to
the address(es)ss(es) above, also submit one copy of this form within 30 days of
13b.Diatnfeclioat type: Amount:
where constructed.completion of well construction to the county health
department of the county
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised Jan.2013

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