GW1--06280_Well Construction - GW1_20241022

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WELL CONSTRWCTION RECORD .
1rh19 teem t9Jnbe used lerst&et owitipSe wells PQr Internal the ONLY:
I.Well ContractorInformation: .
Mao( fj,, .per . . ._
M a .°1.'I 14t�1►i[TBRZOTB9 .
. 612A111 TO flew iPrlowl i
Well Contractor Nam ' ft. IL I
3 224 =A R. R. , i
NC Welt Contactor CetttficollonNnraber ��&oAf.Pit'i'EIt.CAtillt Fier. 1114seed eiblORLINB (ife lte4hte7 , •
t'x .To. oIAMITrER, i TRIMNESS, MATERIAL
Clearwater Well Drilling inc.. 1 R. (Iis a' to'1 !II. n•l JC •
CompanyName `A }(�2 • j�( � D&INNBRCASINOOR NC ffeothermateloI .laop2 ,I-
'�1-aDni c).1't - DIA 4WD
TO DIAMMEIR TRIMNESS MATERIAL
Z.Well t3ottatrltetiot►Petndt#: - � x
Lies all applicable xrAtphfRNctlon permits Ile LYtu' .Slate Yarianec.eta) 'tom
B. - rt. • In.
3.Well Use(check well u$e):
Water Supply Well: '11444718 g TO imAmE1R - sw1SIIE �cttctuteSS' - M f.NI*L '
OAgrieultural €]Mmtieipal/Public IL 6C • in.
17Geothermal(Heating/Cooling Supply) *Residential WatetSupply(single) In.
°Industrial/Commercial °Residential Water Supply(shared) -
°hri anon. FROPi io /11tt►►TaR1AG' Ettt?i,hc M err tor4�1t71lJiulr.
Non-Water Supply Well;.• R' ADll:�a �J 1 (Y1 X P
OMonitoria R. R.
g ORecorcry
injecaou Welt:• R. it:
°Aquifer Recharge QEitnundwaterRemediation lw8"NW - "
['Aquifer Storage and CjlTo Pt�L�i(lrttpti ) • I
ge Recovery _ OS.alirdtyrBarrier FROM no MAMMAL I ttttretwcv tstNstxoD •
IF. it
0AqulferTest ©Stormwater Drainage
°ExperimentalTechnology °SubsidenceControl #' p i
❑Qeotherntat(Closed Loop) OTaacc • 1w.1NO LOG Otttt tAaatMO*Raa.lr,tet isoOZ
TO DffitliIH7ONtnbkLNge,arlltroetttyo raie el"etc.)
17Geothlumal(HeatiunC000ing Remo) °Other(expleinunderH21 Remarks)._ 1I 'R. C—'1b R. '& +C k- ,•r.fr
4.Date Wells)Com feted:�4R�� Welt iDII 5 'it. ki 1, ft.' a C 4CI�_-
{`spa.Well Lat` on 11- r Cons#cuccivr� ��1 �'�$ Ir. 'Le
PaclilylotvoerNeme 12 t3►i Ie po S l- Facllity iDA(ifappflcaWe) —y
VC l b _ ,re.e K LCc e t.1"-e_ Roc :.n�.,.iL:.:,� z.P 1Address,City,uad 2i !L 'Si:REMRK. . OCT 2202eIll .,
uil-he,r 4vrd - . . I
County Parcel identification No.(PIN)
f r• ,,_, -!
Sb.Latltudeand Longitude In degrees/odaptes/seconds or decimal degrees: •
35 ftEweell field,one holism is ssuuffftelent) iii �//� Iill 1 IZ, er'ReadoutN w c reunified Well e,2Q A-
6.Is(are)there a(a):XPermaueet or ['Temporary
By stgning this form,I hereby owe that the nellal as(here)consfrucred in accordance
x61r 15ANCAC DIC.0100 or 1SA MAC OW.0200IRellConstmcrton Swathe*and that a
7.is this a repair to an existing well aYes or kSio ' copy ofshit record hos berarprovtded la the sm.!!omen
ifthls is arepofr,J111 out Amon Roil construction lefermatlon and wren thenatara tfthe
repair under 02l remarks-aectlanoroaOwbackofthhfarm. 23 Site diagram or addi ionalwelldetaltsl
You may use the back of this page to provide ud I well site details or well
EL Number of waifs constructed: conbtntetion details. You may also attach addition&lpages ifnceessary: '
Pm'malttlleWeaIoAWnorr-xatersnpl(y wells'ONtY with'bestrew eaansr sedo ,Pao can
whorl'oeq%Grrn. SUBMITIAL INSTUCTIONS
9.'iontWell depth beiow land surface: tLQ 5 (tit:) 24e.for AI(V(lf, Submit this fort within 30 days of completion of well
For mu!Nplextslls110 all depths Offerer(example-3(a)20�t0''aid 2@1d0'} • constmetion to the following: I'
10.Static water level below tepof casing: l D .(ft.) Division of Water Quality,@Iafotmp I tr Ping Ilnir, -
((weer feed is ober e easing,ass' t`" 1617 Mail ServiceeCent f,Ratelg INC 27699.1617
11.Borehole diameter: IQ (In) 24b.For"(decline Wells: In addition I sending the form to the address in 24a
...I,,�•� �"''t y above,also submit a copy of this form;within 3 days of completion of well
12.Weitconsiruedon method: ro 1h � ^ construction to-the following:. i .
(i.e.soma',rotary.cable,direct push,eta) 'Division of Water Quality,UndergrloundInjection Control Program. •
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) . 5 . . method of test: tit:. :eraSttpielY+&lniet!lott Welke: ip a&ition to sending the forth to
( } bove.also submit onto ctrpy of{his form within 30 days of
13b,pfp(oiectj n type, Amount: of well construction to the county health department of the county
Where G nStrUded. PP
Por,OUIW-I North CarotinsDepamnenofEnvironmentandNaunalResouRq-DivisionofWaterQuality Revised Jan.2013 '

•
Wall Meer sret CaraAcan
Owner Pi.m o Neorwel
icraik
rl r cerigvtihatthe above nieranoedwen wo grouted in appearanceinacceedence with •
all CeuntgWeit mkt
welt-Mar v, I,IQ mamma",
cexa : 3Z CstQ A- na + d: q
capsizal,: Grua:
Total 5(95 CS-I +
casing Type: pv l'� , : (Y, -d
Dimon GO`It
Height
Drive Shoe:
Gis tL•, 5 -