GW1--06285_Well Construction - GW1_20241022

•
WELL COIYSTRRICTIOIjRECORD For Internal Use ONLY:
This Simi canbe used farsingle or multiple well: '
1.Welt Contractor information: .
I'MI
r ! -1 141 ATERZONES U •
q , .
WellComacosNan* n, R, I I '
32.31.eJ, .n. I I
NC Well Contractor Certification Number �6.4UlY4RC�f511�tQ1lbr: dxelb)pRLlNtitt(its "ifexbie)
EROM '[O. D71►MBi6R 7fttCKN[88 MAY$FUAL
Clearwater Well Drilling Inc. j ra Ira D`4 lQ`I�S in- I pVc. •
Company Name no.IN ER-VISS OQR NG(gsotliSfitlalcEpi taop) i I
�►A '� a 1 1 /�1J—. 1�`� t toys •
ro Discierea TRIMNESS •' .MATERIAL
1,well ednbtrtteiio4parmltik u� `r/as �Y�''1 • n. • s1. In.
. Lir1 all applkohle xtdl tdnrtniclloa permits(Le am*Rare.Varianea,eta) I j
EL.• ft. ! lit
3.Well Use(cheek well use);
Water Supply Welk ` .PROM TO :DIAMETER aLorstfa! TRIMNESS MATERIAL
°Agricultural CIMunicipal/Public ft. [w in. I
aGeotlleimal(feetingWCooliFs +ply) 4esideatiat WaterSuPPIY(single) - ft. ; �'
DrndustdaUCommerclat °Residential Wan Supply(chafed) Is. I
To MA r EMPLACEMENT ETHODa6tttooxr
DItrlpation ft' �•� tt n ,y ��
Noo•WaterSuRply Well:
�v ,l.Y�� 1 On i 1
°Monitoring °Recovery R' 't'
knjectiou Well:' ft. f; I .
°Aquifer Recharge °Groundwater Remediation iR SANW VIM Pk . atiS►Neitbte) ' I . ' - . •'
°Aquifer Storage and Recovery f]SalinityBarrier PR
OM O MATERIAL I >iitiPLAcetistsraeerrtoo
DAquiferTest ©S it. IL
totmwater Drainage
°Experimental Technology °Subsidence Control I
DQewhermril(Closed Loop) D7Yacer •2 piW+LlNG LOC(atle ha ditioaat shaft t!oseman&
At TO DESCRIPTION tnlm:to sdyeeektpgtetastendm)
°Geothermal(HeatingfCooling Roam) °Other(explainumder#21.Reanarks!. t O• lap R
4.Date Wetas)Completed:q or,-r W n rn# f« rt ni
-fit,- jL
tt C
Ss.w�i Location: 4€ S'L
9rccn 1 id
Facility/Owner I Faciliity100(ifnppficabte) .,
P ical A,d(d�,Ciittyy, d Zip /'� • !t• .ft.
_ ' OI� I �n 4
V�..�.-ee l i POr`-'' - 48:1s1 itS it 3.7::;4.`... .. 72- . 4.1 _
County Parcel ltfentlfieatlon No.(PIN) L;Y c 1.i: ,_.-J
Sb.Latitude and Loagihnde in degreestminutetheeonds et-decimal degrees:
(if well field,one iatllong is sufficient)II lice: j,
t t a--).' 51 • .N s a' 4� 3511 w "I —e�llJ-)
ofCettefied WedlCotdractor
i 1?ate
6.Is(are)theweil(a): Fenostneot or OTemporary By gntng Air fc,m 1 beet' mar ilea xrltl5j was, °met conspecred In accordance
will SANCAC MC.0100 or ISA NCAC(RC.0200 W&rkCon;unrcrion Swear*and that a
7.Is this a repair to an existing well; °Yes or o ' cap of tat record kw beaapravlded to tile'xrp amen
IfrhIs is a repair,fill out lbtaart well amsinrctlon Infarmationa plain the nature ofthe ! '
repair tinier#21 remarkrsectionorca thrbackafthiafarm. 23.Site diagram or addition)Well&gagat
You may use the back of this page to provide ad [font well site details or well
B.Number of weirs constructed: • construction details. You may also attach additional pages ii" T;
For muliiplo iyeatan rnon,patersvpp(rwellsMI6'withtfies4mtemiturncrlmv,yozraan I
submit on itt w . ( SUBMITTAL 1NS77r4T1ONS
9.Tent well depttcbelow land surface ''mil O 5 (IL) 24n.For All Wells; Submit this form within 0 days of completion of well
For nurk¢duxrlIs&fall depths ljdl,(feria(example-MOO'are 2@llitY) . — construction to the following: j ',
10.Static water level below tep.of casing: LP 0 (D,) Division of Water Qnafty"a Informildos Processing ilnil;
Jf aurer/not is above casing,tee"nn+"tl egg. Mail Service-Center,Ratel NC 276P9161Y
11.Borehole diameter: I.IL 1 U (in.) 24h.For lniectlan Wells: In additioi to sendin&I the form to the address in 24a
above,also submit a copy of this form within 30 days of completion of well
1Z.WcylcoDstroction method; construction tote following.. ;
(i.e..Hager;rotary,cable,direct push,ear-)
Division of Water Quality,Underground dnjectiolrCentro,Program,
FOR WAT$R SUPPLY WELLS ONLY: 1636 Mali Service Center,Itai t:igtt,NC 27699-1636
13a.Yield(gpm)_ 4 Method of teats PIi 9 24c.For Water Sumity&iniestiun Wells: ip ition to sending the form to
• tho addrt (es)above,also submit oael copy of Omtabu within 30 days of
I3b,Disinfection type: pmonnt completion of well construction to the county health department of the county
where constructed
•
Form OW-i North Carolina Department ofEnvhonment end Natural Resources-Division of Water Qualiity - Revised Jan.2013
1 ;