GW1--05858_Well Construction - GW1_20241001

WELL CONSJRUCTION RECORD
This form can be used for single or multiple welts Cron Internal use ONLY:
1.Well Contractor Information:
M a r K ,kt ten 14,WATER ZONES
mom TO iP
Well Contractor Name rt. fL
3 L A R. tt.
NC Well Contractor Certification Number ]&9D f8RCilyl�lG(kw
uttl ea}ft(ttrlb)OR LINER(tf ap�Yetlhte) i
Clearwater Well Drilling inc. etI ft "° a. ._0.1.8T- ht. TN}C1fN�gg MATttaAL
Company Name t l 11,, ,( AA INNER CASING DR WRING(geothermal closed-loop).
2.Well ConatrUCtion Permit#: G��r�4� - (�i 5r) l TO ctAM 38ti THICKNESS MATERIAL
a. f. fire
List all applicable well catutroolon permits(i.e.Calmly,State,Variance,etc.)
n. IL 1
3.Well Use(cheek will use):
—117.Fluting
Water Supply Well: PkOM TO DIAMETER SLOTS/2E THtctctreSS atAresoAL
❑Agricultural OMunicipal/Public n [t to
['Geothermal(Heating/Cooling Supply) Residential Water Supply(single) TM' R i"
❑lndus,rial/Commereiat °Rsidential Water Supply(shared) .i8.GROUT
❑Irsigatiixt FROM TO MATERIAL_ EMPLACEMENT METHOD 6 AMOUNT
Non-Water Supply Well: 1 R• e, C MA( cAi t y.C cj
[Monitoring °Recovery R' ft.
injection Welt: ' R. R
❑Aquifer Recharge °Groundwater Remediation it SANDNGf1AVEL PACE j—"
zaAqulfer Storage and Recovery ()Salinity Barrier FROM TO -- MATB�IAt_ iMMACRMENTMETTtQI
[A uiferTest R• R
q ©Stormwater Drainage
°Experimental Technology °Subsidence Control _ ft. a
OQeothetrmal(Closed Loop) pl racer SO. TAG( additional shoots it seminary)
PROM To nitscawrioN ruder,IaWaen,adtherh t3trq/Ws ally Nee
OGeothe mat Heatin
( B/Coolitlg Ream) °fiber(explain wader#21 Remarks) R• ((CD it ,% p—v"( ,� �,�lr i
4.Date Well(s)Completed: 1\3:)1 i Well ID1# ft' �l UL�! t
Se.Wee Location: G rec� Yti) 1 1 `1 rift' —t f�a=�R
40,t 11 p . Nl t �1� ,�5R !lJ Jet r1C
Facility/Owner Name �-'- t,�t�1LJ Facility IDd(if applicable) 1
R. �s 1 R.
l-C Q5 PL-c/ d1 - (gent- )i , - fL 1 .a.
Physical Address,City,and Zip Sp,PEMA1tK9
i r(-. \/ k1C \_Aci _
County Parcel Identification Na.(Prot)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ' t T
Orwell field,one haloes is sufficient) 27, of 8titatlen:
Si:6 of C Well Contactor Date
6.Is(are)the welt(a): Permanent or OTemporary
By signing this form,I hereby certify that she well(s)has(Irene)constructed in accordance
������...���(((��. with 1 SA NCAC 02C.0100 or l S f NCAC 02C.07f0 Well Con tnrcrian Standards and that a
7.Is this a repair to an existing well: [Yes or o copy afrldx record has been provided to the well owner.
If this is a repair,Jill out/Mast*well construction ln,Thmwrlot,a explain the nature gjthe
repair under 421 remarks section or our the tract of rids jam. 23.Site diagram or additional Weil details:
You may use the back of this page to provide additional well site details or well
g.Number of wells constructed: construction details. You may also attach additional if Par multiple injection or non-woler supply wells ONLY with the same eaiutraMloa,)rod can pages necessary.suborn oneJbon. SUBMITTAL1NSTUCTItN S
9.Total well depth below load surface: 1 l i f5 (ft,) 24a. For Ail Wills: Submit this farm within 30 days of completion of well
For multiple walls list all*ohs ifdl-(ferent(example-$j)200'and.ttld(P) consbuction to the following:
)
10.Static water level below top of casing: <.�(((' J. (ft.) Division of Water Quality,Information Processing Unit,
If miter level is chose casing,use"+"t i 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: Ll,i 1 `J
(in) 24b.For Infection Wells: hi 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 l', ajl..4. consttuction to the following:.
(i.e.auger,tntary,cable,direct push,eta.)
Division of Water Quality,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: t636 Mau Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of tests CI 24e.for Water Supply&Iniection Wells: ip addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
136 Disinfection type: Atatoant; completion of well construction to the county heath department of the county
where constructed.
Fosm OW-i North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised Jan.]013

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