GW1--05754_Well Construction - GW1_20240926

WELL CONSTRIJCTIOr(RECORD For internal ore ONLY:
This form can be used for single a multiple welts
1.Well Contractor information:
M a r K A-,►nrl. A4,WATER ZONES
FROM TO DESCRIPTION
Well C.oettactoe Name ft. ft.
32-•D17 A R. R.
NC Well Contractor Certification Number 15.OUTER CASINO flayalu-cited w'elh)OR LIWLQt 1
Nan 'r�tAL
Clearwater Well Drilling Inc. —� ft. 1 yi R. L(,gT�in. y�,�;
Company Name y ) (� / �(h Ali.INNER CASING QR TUBING(geothermal dosed-loop)
i'"�
SS C]( T + l L 511��D I ROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: n, ft. k,
List all applicable well construction permits(i.e.County.State,Varlancle ale.)
It. IL Ia.
3.Well Use(check well use): 17. EN
Water Supply Well: FROM TO DIAMETER SLOT MU THUGS MAYERML
°Agricultural Clnicipal(Public r ft. i° '
Mu
°Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) R R' M. -^
❑industrial/Comme:rcial °Residential Water Supply(shared) -49?
rUT
i To MATERIAL SMELACS MIINi MITHOD A AMOUNT
°imgation '� %1
Non-water Supply Weil: i it- ( it. ti �-1(1cl t m 1Xf�l
°Monitoring °Recovery h' ft.
Injection Weil: ft. ft. ---
°Aquifer Recharge °Groundwater Remediation 19 SANE)/ V$L PA (if apglkaitlei -
°AQuiftr Storage and R FROM TO MATERIAL RMP ACEMENTmEPHoo
xovery DSalintty Batrier
R. IL
°Aquifer Test °Stormwater Drainage
ft. n'
❑Experimental Technolo
gy ❑Stibsideace Control �
❑Geothermal(Closed Loop) °Tracer F O 111AIINT 1AG( .at slaecb it atxasary}
F�mM TO �HO'N(star.ltirdarR.asWraekvpetin4eshyete.)
°Geothermal(Heating/CoolinggjReturn) i'DOther(explain under 421 Remarks) I R' 1L R• &A+ t ►r--
4.Date Well(,)Completed: O ap aT Wes rDAt i S n' �4)ft' ant}e
sa.Well bastion Le-r\--t rG — 3Cil R' w5 a a Gn u ` :
M i camel Owens ft.
Feeility/Owner Neine Facility IDE(if applicable) ' --' � - `1 i_tam
ft. ft.
14-3 Sk.mr\ 1 .1,110,- ' 1 bati,r4 n. R. - SEP 2 3 2024 "Physical Address Gay,tad Zip � ,� /� C�t�-A {) M 1
p- =1.REMARKS
1.f 0n - .,. ...,4,i -:ir.li-.,'.iT.d
County Parcel identification No.(PIN) C 3..:. =
54.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: `.
22.C(if well held,one Wong is sufficient) 1letatlse•
_5t e94i ri " N a' IC `r w L
, 'a 1 -d4
Signs oft:ertified Well Contractor Dale
6.is(are)the well(s): *Permanent or OTemporary
By sign, this farm,I hereby certik that the weft)ear pmrei constructed in accordance
w•itil 15A C 02C.0100 or!SA NCAC 02C.0200 Well Catutntcrion Standards ono that a
7.is this a repair to an existing well: °Yes or N, copy of this record has been/C provided to the well nRnrr.
If this is a repair,fill out known well eortstnretton IdtfornurtMn and explain the Honor of the
repair under#21 remarks section or on the back of Mir farm. 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 snatch additional pages if necessary.
For multiple injecior,or non-Rioter supply wells ONLY with the same construction,you can
rubnit oxefbnn. SUBMITTAL 1NST'UCTIONS
s- F
9.Total well depth below lend surface: ..)0 (ft.) 24a. rat An Media: Submit this farm within 30 days of completion of well
For mukluk Rolls list all depths if different(example-3(J200'and 2@l t . ' constriction to the following:
10.Static water level below tap of eater: LQ V (ft.) Division of Water Quality,Information Processing Unit,
If Rater doe/is abort eating,use�-+•• 1617 Mali Service Center„Raleigh,NC 27699-1617
11.Borehole diameter: (S/ I� (in) 24b.For Inleedon 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(9 111114 construction to the following:
(i.e.eager,rotary,cattle,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center.,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of teat: i q
24c.For Water SuDDIP&Injection W'YellIE In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136 Disinfection type: Amount; completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environment and Natural Res lurces-Division of Water Quality
Revised tan.2013

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