GW1--04963_Well Construction - GW1_20240816

WELL CONSTRJJCTION RECORD For Internal Use ONLY
This fwm can be used for single or multiple wells
1.Well Contractor Information: .
MarK A11 '1 , 14,WATER ZONES
t TO DHSCRtPTI,
Well Contractor Name n, ft.
'^ /� , R. a.
NC Well Contractor Certification Number gB.'f1T8R CASiNg(far ultl-eagd welts)OR Lunt tf aptIkspte)
IiA�OM TO DIAMETER Tn „ MA 78RIAL
Clearwater Well Drilling Inc. R ft. = n. , In. i
Company Name cab 1PiNERCASING I ' TUBING c:otiterinalclosed-loop)
N �{ 1 L1 ' �•.<s1 &ie DSAMETRR TNIOXNFSS MATERIAL
2.Well Construction Permit il: SIC ft. IL to
List all applicable well canstett/lon perntits(i.e.Comity.Slate,Yorian a.elc.) — _
ft. ft in.
3.Well Use(check well use): 17.9CRYBN _
Water Supply Welt FROM TO DIAMETER MAT SIZE T ICKNEES MATERIAL
DAgricultural C7Municipal/Pubiic R is
❑Geotheral(Heating/Cooling Supply) ,Cr3Rtesidential Water Supply(single) rt. R to m
❑IndustriaUCommcrcial ❑Rcsidentiai Water Supply(shared) —la C1°BT
FROM TO MATE , PWRc*MtlhT M A TROD Aroma ,
Obligation
MATERIAL HM .� `,
Non Water Supply Well: ._.- i ) ft. ppmfl r t f1 1 l� X e
DMonitoring 0 Recovery ft. ft.
'Injection Well: ft. it.
°Aquifer Recharge °Groundwater Remediation 19t SANWGRAYRL PACK 0t p�c
ClAqulfer Storage and Recovery C7Salinity Barrier FROM to MATERIAL YA1YLwt:wilsNT METHOD
n. ft.
°Aquifer Test ❑Starnwater Drainage
°Experimental Technology DSubsidenee Control n. e.
OQeothc Ia.f1Rli,LING LOG(attach additional.
rmol(Closed Loop) °Tracer ' shots TO DESCRIPTION fakir,berdaeaa,saeete ytrnh, rte.)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (' ` R. LOnU Ft*
/ i n�/y 4 ^t;Y un4.
4.Date Well(s)Completed: f-2 -�T Well[D# nnK R' ICI_� '- IL.5�'S \i
MI
N�ial dlc tIZ.". 229" ri w
K R R
Fag7iry/OwnerNema Facility lDN(if applicable) i }rt. -
. ft. . A: '_ it L;.J
ft. ft. ,
P lam"City,and `' RMARxs CAI I G 1 L 2024
County Parcel Identification No.(PiN) w r Jt 3P
Sb.Latitude nod Longitude in degrees/minutes/seconds or decimal degrees: 22.certifleatk(if well field,one among is sufficient)
L35' l�' Z" N , .t 5 ' o'' W _ �LA r —1— 7_,9 Zy
signature of Certified Well Contractor Date
6.is(are)the weil(s): ikrerrnaleat or ❑Temporary
By signing this farm,I hereby cent&that the well(sl oar(Mere)mnstruard in accordance
with ISA NCAC OIC.0100 or ISA NCAC 01C'.0100 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or t1tJo copy ojthls record has been provided to the w1r/I miner.
If this is a repair,fill out known well construction Information and explain the nature of the
repair under#2i remarks section or on the back of this_jarm. 23.Site diagram or additional well details.
You may use the back of this page to provide additional well site details or well
B.Number of wells ceostructed: construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONL V with the sane camrtrartlon.van,can
suborn one form. SUBMITTAL INSTUC IONS
9.Total well depth below land surface: .2. (ft.) 24a. For All Wells: Submit this firm within 30 days of completion of welt
For multiple untie hoe depths i'different(example-30200•ard 2@1&) construction to the following:
10.Static water level below top of casing: LOO (ft.) Division of Water Quality,Information Processing Unit,
Ifirater/earl is above casing,use"+"ti 1617 Mali Service Center,Raleigh,NC 27649-1617
11.Borehole diameter: S (in.) 24b.For i iled:Ion Wjile: In addition to sending the form to the address in 24a
rC>,�"!�j above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: I construction to the following:
(i.e.nuger,rotary,ruble,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center.Raleigh,NC 27699-1636
13a Yield(gpm) Method of test t 9 24c.for Water Sapoly&Jniestion'f:lk/, )p addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
I3b.1> infection type: Amount; completion of well construction to file county health department of the county
where constructed.
Form OW-t North Corolla*Deparrmcm of Environment and Natural Resources-Division of Water lily
Qua Q � Revised Jaw 2013

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