GW1--05832_Well Construction - GW1_20241001

WELL CONSTR>I.JCTION RECORD
This form can be used for or multiple wells For Internal Use ONLY
I.Welt Contractor information:
M a r ( A-I Le.n 14,WATER ZONES
FROM TO DeSCRIPTIM
Well Contractor Name R. ft.
3 L...?W A R. It.
NC Well Contractor Certification Number IS.OUTER CASING(tar tut-eswtt wells)OR LINER Of a pie)
PROM TO DIAMETER { THICKNESS MATeRIAL
Clearwater Well Drilling Inc. ( ft. `�l D n. LQ r1 i)la'• I 7\(Company Name 16.INNER CASINO QR TURING(geothermal clod-loop) i
2.Well Construction Permit il: ltM04 TO DIAMETER TRK MATentAL
ft. ft. la
Lint all applkohle well censtnietlon permits(i.e.Calmly.Stole,Variance,etc)
ft. ►L is.
3.Well Use(cheek well use):
17.SCREEN
Water Supply Well: PROM TO DIAMETER SLOT SIZE 'THICKNESS MATtytlA4
❑Agricultural °Municipal/Public n (t to
°Geothermal(HeatingfCooting Supply) Atesidentiai Water Supply(single) __ H 1n
❑lndustrial/Commerriat °Residential Water Supply(shared) .-12'C U9'
❑hri�atitsn FROM TO MATE I _ emes.Ac(iM6NT M TBOD A AMOUNT
Non-Water Supply Well:
I it. 6? 't. re 11 Yi Di- i' 1 t
❑Monitoring C]Recove n. n.
�` r
Injection Well: R. ft.
OAqulfer Recharge °Groundwater Remediation 19.SANt)1G)IANRL PA emallogl. )
DA infer Stour and R >aROM TO EMP ACEMENTMETHOD
q StorageRecovery °Salinity Barrier n. ft.
°Aquifer Test OStormwater Drainage
17 Experimental Technology n' e.
°Subsidence Control
OOeothcnnal(Closed Loop) f Tracer NGT LOG(attach additional.theta N neeesary)
Frit7O DESCRIPTHDN tdbr.trardarne 11,11SueS brp,,ttala alas.etc.)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) ( ft' Lv c) R. S/?; VI/I rdt' i 1 T_
1,Date Welt(a)Completed:0 n o_�i Well MS44' tE S C J i�lu t `
R. Tt,
Sa.Well Location: / t ft. rt.Ni a t K CI- C I n<`ILI I�--1�1 ft. - t)
Facility/Owner Name Facility 11)t1(if applicable)
1 1� Cfl Qd , For>t City ' n. 1 n 1 _ t rr ,t l 20Z4
ritysicalAdddreesss,Citty,and Ziipp �C
u 1 i 1Ix o r 2F.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude `2.t i
in degrees/minutes/seconds or decimal degrees: 2(dwell field,one itulong is sufficient)
C / /
Sipaa feeti6ed Wel r Date
6.Is(are)the well(s):' Permanent or °Temporary
By sighting this form.I hereby cerRfy that tVe'refits)Min(ute)constructed in accordance
r+itl,l SA NCAC 02C.OI00 or 15A NOW arc.0200 Well Construction Smarter r end that a
7.Is this a repair to an existing well: Oyes or ,(No copy culls record has been provirkd to the Well auner.
If this is a repair,fill out knurl well construction lrformmion and explain the nature of the
repair under#2I remarks section or on the bock ofthis form. 23.Site diagram or additional well detaUs:
You may use the back of this page to provide additional well site details or well
B.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-Ester supple netts ONLY with the tame o ostrticatm.you can
submit oneJbrrn. SURMITFAL INSTUCTIONS
9.Total well depth below land surface: ( )V F (ft.) 24e. For MI Wetly Submit this form within 30 days of completion of well
For rnulgple sells list all(-ATMs d(ffrrent(example-300 200'and 2@1 d0') consttuction to the following:
10.Static water level below tip of casing: LQL (ft) Division of Water Quality,,Information Processing Unit;
If unto/reel is above caring,use••+• 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (.C (I (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
l�f V l /} above, also submit a copy of this fonts within 30 days of completion of well
t
12.Well construction method: 1 C `-�( construction to the following
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Centro!Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Melt Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm �') _ Method of teat ) 24c.For Water Saintly&Injection!j:01 sp addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type; Amount: completion of well construction to the county health departlnenh of the county
where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Divisiott of Water Qwl1y Revised Ian.2013

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