GW1--05867_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD For internal Use ONLY:
This tuner can be used for single or multiple wells
1.Well Contractor information:
M a r x ktla) %I Arai z leas DESCRIPTION)
Well Contractor Name rt. 2
.s 7-.? / _.A R. R
hIC Welt Contractor Certification Numbs —6 MIR CASINO Nor ultl-asted"RN OR LINER(if:agellegsle)
rxon� TX/ DIAMETER 7RICKNES3 MATERIAL
Clearwater Well Drilling inc. 1 fL n. ( ei gin*
l j
Name _ t id.INNER CASING OR'WISING(geothermal ate-loop) PVC-
Company
2.Well Construction Permit#: C 1-\- — �r5 a1 lam'` n. TO ft. DIAMETER In. MEEKNESS MATERIAL
List oil applicable well construction permits(I.e.County,State,Variance.ek.)
R. It. Ia.
3.Well Use(cheek well use): r'i7.SCRERil .
Water Supply Well: PROM TO DIAMETER SLOT SIZE rnrctcwass MATERIAL
°Agricultural unicipal/Public n h In
C]M
CJGeothennal(Heating/Cooling Supply) Residential Water Supply(single) _ ft a. In.
❑lndustrial/Commercial °Residential Water Supply(shared) J&GROUT _
❑hTigatioo Fitpi t MATEEI4t, j EMPLACRMENT ME'rhOD at AMOVNT
Non-Water Supply'Well: L r C O' ,�t-i nTh Ci
°Monitoring °Recovery R. ft.
Injection Well: ft. n.
°A uifer Recharge -
9 °Groundwater Retnediation 1R SANA+G)tAYSL M �IfaPptttatlM) • � ,
°AquIRT Storage and Recovery °Satin DaniaFROM TO MATERIAL I Iit1eLACEMENT METHOD
ft. IL
❑Aquifer Test °Stonnwater Drainage _
n. n.
°Experimental Technology °Subsidence Control
❑Qeotherraa!(Closed Loop) °Tracks :.oe Ettp.LiNG LOC(apart¢additional amen�a temeary)
aR TO ORICIUPTU)N tester.lr w adae ,aaWroeti t e)vale ate.etc.)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) (�J R• D• R. -3 + C l-+
4.Date Well(*)Completed: �q WellID//
O? ft •� 11 R' as-
Sa.Well Location: `
_ n. .�1- R ,il S•` • (I
VC-
ifsa J
Facil ty/Owner Nmne lam{- ki 13 Facility IDtI Of applicable) G. ft. O rT r 2a24
A It .lilill g ,f' —0—, 1\i'll t t 4)11 M ft. ft.
P I Address,City,and Zip fn(,:t�i;6:f,-1 !'�' l
©I � 2i.REMARKS at.-C. .;
County Parcel identifiatien No.(PTN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 C it:
(if well field,one laulong is sufficient)
t5 a99 5g N � l 1 L + W � —3o-a4
s-' of edified Well Dale
6.Is(are)the well(a): ,Permanent or ❑Temporary By signingthis I herebyrr form, rttb,that the;wilts)was(Isle)corm otter./in accordance
with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0200 Weil Construction Standards and that a
7.is this a repair to an existing well: °Yes or o copy of this record has beep provided to the well owner.
if this is a repair,fill ant known well construction Information and explain the nature Odle
repair under il21 remarks section or on the bock of this farm. 23.Site diagram or additional well details;
You may use the batik of this page to provide additional well site details or well
S.Number of wells constructed: cons ruction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit anetium. ' ' SUBMITTAL INSTUCTIONS
11
9.Total well depth below land surface: ' "�[f-- (IL) 24a. For AR Welts: Submit this form within 30 days of completion of well
For multiple%mile list all depths Ifdlf(erent(example-.t(a)200'and 2@lO0') construction to the following
10.Static water level below top of casing: Li L i (IL-) Division of Water Quality,Information Processing Unit;
if ester level is above casing,use-+.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ( , (In.) 24b.For halation 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; rU+4,..ft j construction to the following..
(i.e.auger,;Maly,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Caner.,Raleigh,NC 27699-1636
13a.Yield(gptn)_ Method of test: i24c.for Wader Suvoly&imleSttoa 1yg(e: Ip addition to sending the form to
the addresses) above,also submit one copy of this form within 30 days of
13b.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 Nernst Resources-Division of Water Quality Revised Jan.2013

Wall Qom'SalMime collassisams
owner \
I hereby cesttlythatthe abovergrouted appearance in accortienoe with
an County whit
urea DinerJ CiL_.. - .)f i s ' J
coon: e
Ca**TYPIX
Le
Wye Shoe,
GPM: '�