GW1--04961_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wellsL 1
Fit internal Use ONLY:
1.Well Contractor Information:
MarK Ai 1 N i , 14/WA ERZONICS
most ro tascnirrto
Well>ContractorName ft. ft I_
3 i1n i _ A r R. h.
NC Well Contractor Certification Number tS.OUTER CA$)NG(fbr gwltl.pid a gls OR LINK if a '
VROM TO jii DtAMtiT6F�� Tpt Ngga MATtiWAL
Clearwater Well Drilling Inc. fe. ri-1 h. Lc, _ tn. l
CotnpanyName Ili INNER CASING OR TUBING die `�\
nn Ir— (yeotermal closed-loop!
2.Well Construction Permit tit: CS,' r��S- J tYROM TO DfAMCTR9 micxetasa _ MATERIAL
h. f. to.
List all applicable urnanstruction permits(i.e.Copt(,Slate,Variance.etc.)
n. ft. in.
3.Well Use(check wen use): _
17.SCREEN
Water Supply Well:
fitOat TO DIAMETER BLOTBIPZ THICKNESS MATERIAL
°Agricultural °Municipal/Public R n. , le.
°Geothermal(Hating/Cooling Supply) `Residential Water Supply(single) R. In
Olndustrial/Commercial °Residential Water Supply(shared) Ja CRotrr
OIRigetion FROM To MATER4t, 5MP►.Ach`MENT MIiTROD a AMoVNT
Non-Water Supply well: , 1 "' t_9 U " 4 cesi\ '}1~ i-71 l X cr-1
°Monitoring °Recovery R. n
'Injection Well: ... —r
ft. ft.
°Aquifer Recharge DQroundwater Rernediation ID.SANWG)L VSL PA (41aponeabtai - 1
C/Aquifer Storage and Recovery E33atinity Barrier FROM n TO R MATeRut EMPLACEMENT METHOD
'°Aquifer Test ❑Stotmwater Drainage _
°Experimental Technol R $
ogy DSubsilieltce Control
DOeotherrnal(Closed Loop) D IYace r :It II i 1 LOG(Mtaet seienyaal Omni it Mont*
DGtothermal(Heating/Cooling Ream) DOther(explain under/21 Remarks) To �`ta�r, tedlhoelte—Erala,tse,etc.)
4.Date Wen(s)Completed: ) -2 5-Z4eli(IV 51 n. 1 CD 9i-ocnii
ft. R.
Sa.Well'Location:
e. n
llchc.,17. .C,Ubr — n a '
•
Facility/Owner Name Facility IDIi(ifapp!ttcable)
r I R. ft
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Ic Jlai, k'dV "N rl`\ EJ fi.' -n.
Physical Address.City,and Zip L
�
r �� 2i.I yt$MABKS i�I : i
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/militates/seconds es/militates/seconds or decimal degrees: 22 )
(if well field,one latliong is sufficient) 22 c tier!; I
,k.
.I
Signature feenified Colas r Dad
6.Is(are)the well(a):I*ermaaent or ❑Temporary
By signing is form,1 hereby cer116.that the sell(s)weal Owe)constructed in accwdonce
with 154 Nt AC 01C.0100 or 1 SA NCeiC 02C'.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Dyes or �c]No
If this is a repair,fill out known well construction information and lain the nature of the copy Otitis record has been pruvidnl to the urn miner.
repair under#2I remarks section or on the back of this form. 23,Site diagram or additional Weil details:
You may use the beck of this page to provide additional well site details or well
S.Number of wens constructed: construction dedaits. You may also attach additional pages if necessary.
For multiple injection er non-water supply wells ONLY with Ike same construction,you can
submit one firm. _ SUBMITTAL INSTIICTIONS
9.Toast well depth below land surface: (ft.) 24e. Far AR Welk: Submit this fitmt within 30 days of completion of well
For multiple weeltt list oil depths iIf different(trample-.1(ia 2110'oar!2#.100') ' ' cotisbvction to the following:
10.Static water level below top of easing: (ft.) Division of Water Quality,Information Processing Unit,
If inter level Is abort casing,use"+"1 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: t C O (In.) 24b.For Injection Wells: in additica to sending the firm to the address in 24a
y above, also submit a copy of this fort within 30 days of completion of well
12.Well �r`.}construction method: � ' construction to the following:
(i.e.auger,rotary,cahle,direct push,etc.)
Division of Water Quality,Underground injection Control Program,
FOR WATRR SUPPLYWELLS ONLY: 1636 Mud Service Center;Raleigh,NC 27699-1636
13a.Yield(@pm /
) t/ t
Method of test: 1 L�q 24c.for Water Supply&infection,E.c,WL,jp addition to sending the form to
the address(es)above, also submit one copy of this icon within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Fonn OW-i North Cirolina Department of Environment and Natural Resources-Division of Water Quality
Revised ran.2013

owner; , lei C,U} h ia-n r wA
Pante
Ibooby ceedtythat the awe referenced v vas grated in ale accordance with
all County Mem
Wall Noble MtuA,
3as1Q - ,4 Ewe .
Casing Typer,2
V GThicket= f-NN q.-e C
Diameter V Vf5
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