GW1--05864_Well Construction - GW1_20241001

WELL CONSTRVCTIO{FECORD Fin interuuI use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
NI a r K Ai i n r1 14,WATER ZONES
-
MOM TO DESCRIPTION
Well Contractor Name ft, fL
3 Z.?S A f:. ft.
NC Well Contractor Certification Number ^Il6 O T ER CA$lN(j(fir NFeajg4 fib)OR LINER(if 0,,Hesble)
$xoM TO D AMaTne THIC1CNESA MATERIAL
Clearwater Well Drilling Inc. I ft. ", Le't .;,,, 1 n\;C
Company Name ' , le.ROM CASINO I ' TIMING eothimu al coned-loop)
1.Well Conatruelion Permit#: 3l-)a 3 -- 0(Lo - •, �L'� DIAMETER l tfKP4Fss MATERIAL
tt, ft. Ca.
List all applicable Well contlructlaa permits(Le.Corny,Saaee,Variant*.etc) —
n. ". to.
3.Well Use(check well use):
F7.SCREEN •
Water Supply Wes: PROM " TO rimmEllOt ,SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMtmicipaVPublic " B 1"'
°Geotthermal(Heattg/Cooling Supply) °Residential Water Supply(single) B ft. i" ~
❑lndustrial/Cammertial °Residential Water Supply(shared) --(4.9
❑Irrigatitxl TROM TO . MATERiAt� EPOLA.CEMEt4T METROD A Wawa
Non-Water Supply Well: \ 1 "• r�C' ft. e Cil`1'ill co 1 u C1
fMonitor•ing ❑Recovery R. ft.
�
Injection Well: n." ft.
❑Aquifer Recharge []Groundwater Remediation 19.SAN VEL PA lift eaptl,
[]Aquifer Storage and Recovery °Salinity Barrier t oltt i1 xtATc n. To ttut tutu eeeatiwrMETHoa
°Aquifer Test OStormwater Drainage
°Experimental Technology ©Subsidence Control " "
Ot7eot)temwl(Closed Loop) 07 rnccr ilkOlHW,iNG LOG(aft addlll nil slash if an:n ary)
envoi To I otrsctetrn oft Dish,
aavrodt y m►a she eh.)
°Geothermal(Heating/Coolip$Rctunt) °Other(explain under 1121 Remarks) ! 1 B• lX V "• `-'I`�-(��-: vi
4.Date Well(s)Compietedt�."a Well DM S11 `-' i 1�1 t/,i .
Sa.Well Location: l "' [ 1 R Ne (s
Nici.i 4- a42.rYAlr(1 GtiotniX-tt ft. it•
Facility Name Facility lDM(if applicable) ft r J t `. a• !*v i
(Ql$ Cre 1,side, Circle _1 V
• ft' ft. ! 2024
t atlas City,eMz;p 2t.REMARKS
County Parcel identification No.(FIN) Q t sa
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one bilking is sufficient) n. thaw
3' 40-1-10 aa CCMR It(i,
W / ' ELI' A&--__.,
`/ tn Signanuc f Certified Well Contractor ��! C7f`1'
6.is(are)the wel(s): mPerast or °Temporary
\\ By signing thu form,I hereby certlfr drat the neB(s)nos(bate)constructed in accordance
�/ with 1 SA NCAC 02C.0100 or ISA NCAC WC.0200 Well Constnecron Standards and that a
7.iA this a repair to an existing well: °Yes or o copy of this record has been provided to the Well merrrr.
If this is a repair,fill out kiloton well construction information and erpluin the nacre of the
repair under#21 remarks section or on the back atria:form. 23,Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
Far mull/ple injection or non-water supply wells ONLY with Ike lure construction,you eat,
submit onefoem. 0 SUBMITTAL INSTUCFIONS
9.Total well depth below load surface; �( ' go24a, Far Ail Wells: Submit this form within 30 days of completion of well
For multiple nails list all depths I/different jerornple-.4)200'and 2S1 ') construction to the following:
10.Static water level below tap of casing: (CC (ft.) Division of Water Quality,information Processing Unit,
if miter level is above casing,bur•'+" \ 1617 Mail Service Center„Raleigh,NC 27699-1617
11.Borehole diameter: I 0 (in.) 24b.For Injection 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: le 1I/l_ I LA construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Fragrant,
FOR WATER SUPPLY WELLS ONLY: ' 1636 Matt Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �Ci Me
thod oft : k iq 24c.FOX Water Suooh'&infection VEelk;_jp addition to sending the form to
the addresses)above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amami; completion of well construction to the county health department of the county
where constructed.
Frarn OW-I North Carolina Department of Environment and Natural Resources--Division of Water Quality
Revised Ian.2013

Wall Delft 1161116600 cseallesdoi
Omer c i,cinna
PennitLaQ
that iba above refermced 1vac grouted in appears=In accordance watt
all Cooly 1414 ndea
Dotter \\ ' V '":" SIP •
Cttaeatea: 2Lc Doe Grouted:
caletructtan: cimut
Ibtal Depttr_„a25 CISM-K-*
CalingTPe4\
Caking Defth:-16---
Diameter: t-k'1
Drtve Shoec
GPM V