GW1--05753_Well Construction - GW1_20240926

WELL CONS`KRUCTION RECORD fror internal the ONLY:
This form can be used far single or multiple wells
I.Well Contractor Information:
•
M rk r K AlI e n 140VATB1t ZONES
ROM TO OcScRiPTtoN
Well Contractor Name ft. ft
NC Well Contractor Certification Number 16.OUTER CASING((btufl r g -cued weRs)OR LINER(If applicable)
FROM To DI AMST6a. THICRNESR MATERIAL.
Clearwater Well Drilling inc. i fe _Q t a ft. j r <,,,a. ` )\,,C.
ConpanyName yJ�J� (� 1 /� te.INNER CASING QRTI1RING(teol rr l
2.Well Construction Permit rY: o?I I tT V if T lY �l a TO
IL DiwiM67HP.,p_ TH�) MATERIAL
Lint all applkable well a nrtrrtcrlon permits(i.e.Cotmb,.Stage,Varlance,etc.) .... ,
ft. R in.
3.Well Use(check well use): Lt7.SCRt81lt Water Supply Well: PROM TO -DIAMETER ,SWTSITE THICKNESS MATERIAL
°Agricultural MunioipalPublic ft it In.
D
❑Geothermal(Heating/Cooling Supply) 01jlesidential Water Supply(single) _ iw R. In
❑IndustriallCommercial °Residential Water Supply(shared) -I "
FROat To❑ln igfltioll rr�� MA �: .L"�" AaM T mono A AINOTINT
Non-Water Supply Wei: ft. oeffy 1 l � . ��
°Monitoring °Recovery ft' ft
injection Walt: ft. ft.
❑Aquifer Recharge °Groundwater Retnediation $9.SAND/GRAVEL PA a ppileabf
ElAqulfer Storage and Recovery °Salinity Barrier —oM TO MATERIAL aMn wecMSNTMarRoo
ft, ft.
()Aquifer Test °Stonrtweter Drainage ft. ft.
°Experimental Technology °Subsidence Control
OGeotherm$1(closed Loop) g7Ya tt DIWdNGG LOG(attac ecw h additional dusts if nary)
P�aoM To i Dc_�t'Rlel o�N(�;rLc=4- a a,adNyek- plate:Ise,etc.)
OGeotht7rrtal(NeattingjCtwlir�Rehm') Other(explain under#21 Remarks) p nI R' �Qf5� rt. �-iu' tiy-1�1�.yf �(,(�
1.Date Well(s)Co feted: - 0 f�•�YelllIIDA,t�n ''�"5 f V� it r5rn nit(
Sa.Well Location:���� �VOU� ViCI -S ft
k C..x)J,t - Ud (S _ � ' .,_ _ _
Facility/Owner Name Wit, Li i Facility IDS(if applicable) ' _• t s .•�I d -
ft. R
a:_en1C- V'I et..CD Dr , ft. IL' SIP 2 u 7024
Physical Address,City,sod zip 2).REMARKS 1
Oen . r) :.
County Parcel Ideraificadon No.(PiN) I.•.1_ ;
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lauiong is sufficient) flCastial;
ofCeeC 1Caairactor Dale
6.1s(use)the wells): Fermaaent or ❑Temporary s i thb arm I lrareb
"'ors,
' 18rt ng I r N'Ark CPI
the Mel1(s/Mvs S.
m mns?uttrd in a and
that
a
nOb I SA NCAC DIC.0I00 or 1 SA ArCAC 01C.07a0 Well ConsrnncNan Staniar&and shot a
7.is this a repair to an existing well: Dyes or giNo copy ofthts record ban been provided tote Hall miner.
If this is a repair,fill out boom,well construction Information abcPexplain the nature of the
repair under On remarks section or on the bock of this fons. 23.Site diagram or additional well details;
Yem may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-Muter supply wells ONLY with the yenta construetbw,you can
submit oneJbrm. 311RM1T FAL INSTUCTiONS
9.Total well depth below land surface: SO J (IL) 24a.jror AN Wells: Submit this form within 30 days of completion of well
For multiple nulls list an depths if dtfferenr(uomp/e-4:000'and 2`r@/tilr) construction to the following:
10.Static water level below top of casing: �-l� (R,) Division of Water Quality,Information Processing Unit,
If inner level is above casing,use"+•' ` 1617 Mail Service Center.,Raleigh,NC 27699-1617
11.Borehole diameter: U) ',j (In.) 24b.For infection Wells: In addition to sending the form to the address in 24a
t� �/� above, also submit a copy of this form within 30 days of completion of well
1
12.Well construction method: � ! :1 Lj construction to the following:.
(i.e.auger,rotary,cable,diroct push,etc.)
Division of Water Quality,Underground injection Control Program,
FOR WATER SUPPLY;(-Z WELLS ONLY: 1636 Mau Service Center..Raleigh,NC 27699-1636
13a.Wald(>iPm) Method of teat: 4,)ei 24e•far Water Supy$t pl infection Wes; In additionto 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 Natural Resources•-Divisiae of Water Quality Revised Jan.2011

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