GW1--05756_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD For Internal use ONLY:
This tom can be used for single or multiple wells
I.Well Contractor information:
M al-K A-1 ten , 14t wATlila zoN1t.S
1ROM 10 DCscRIrrigN
Well Contractor Name R ft.
3 L A ft. R.
NC Well Contractor Certification Number q&OMJTER CASING(lie dlti-caged steiisj OR LUNRR(Ra cat.)
c*ROM To DIAMETER _ THICKNESS MATERIAL -4
Clearwater Well Drilling inc. l ft. IQ l R. (D'' On'
pVe
Company Name OS
)C�l^ f (� {��( so.INNER CA$ING t •TUBING - hernial ct _
2.Well COnstrtu nPermitf(: OS5 - fJ00 T 1 V,,O- _1 r •t DIAMETER_ TRtCYN88s� MATERIAL
h. ft. in.
Lis,all applicable well construction permits(i.e.Coim(y.Slate.Varktflea.etc) — _
R. R. in.
3.Well Use(check well use): r7.FREEN —
Water Supply Well: F1tOM TO DIAMETER ,g;.OTSIZE THICKNESS MATERIAL i
❑Agricultural OMunicipalfPublic
dCkothetmal(Heating/Cooling Supply) Residential Water Supply(single) h R.
Dindustrial/Commercial °Residential Water Supply Pp Y(shared) GROUT
FROM TO . MA
alrsigation TUNA L UB1.ACRMtiNT MarEOD a ARMOVNT
Noe-Water Supply Well:
` R. 0 G n: .C l7 me,t,t( _ j�C.Q (t
°Monitoring °Recovery
Injection Well:
r ft. ft.
°Aquifer Recharge °Groundwater Remediation is.SANWGGtAyi}I.PAPS(if t lieiyhisie)
ClAquifer Storage and Recovery °Salinity Barrier mat in MATfiRIAIOD
R. R.
°Aquifer Test OStormwaler Drainage
°Experimental Technology ❑Subsidence Control ft. o.
❑Geothermal(Closed Loop) °Tracer 29 NC LOG(attach+iddhlleoal thasb U aettatany)
D6-9CRiYfk3N ink,IuA{e sriNodc !tarn saw,etc.)
DOeothermal(Heating/Cooling RYetturn)4 °Other(explain under#21 Remarks) I rt- I d' R. Set, .�'4 ,
4.Date WOO) J" I - Wen w# i t I, W ft- /la it ����l r.l 1l I�T�
5a.Well Location: 't R 'T 4/�-�1U
7 ft' 50Sn. ()rank-ie.
Facility/Owner Name Loa I Facility IDE(if applicable) i *.
ft. ft a.1a.. : 1...(i'
l I rile i —Dann "—ft--; n. a g o RN
Physical Address,Cky,nod Zip 2i.REMARKS —
�1 Ctu"son • . . .-, .-.1!1st
County Pared Identification No.(PIN) /3
5b.Latitude and Longitude in degrees/edentes/seconds or decimal degrees:
(if well field,one awing is sufficient)
35' 32- .ctct ` S- S'al 40t 'ILL D1 w ii f -�1
/ = of Certified Well ct`or
6.Is(are)the welt(a); {OPermaaeut or OTemporary
'\ BY s/gn flail-OM 1 hereby cer*that dm weill's;was(kit,constructed in accordance
with 15A NCAC 02C.0/00 or 15.4 AtCAC O2C.0200 Well Construction S7andar5Lr and that a
7.is MMb a repair to an existing well: °Yes or Ne copy alibis record has been provided to the well°Inner.
if Ibis is a repair,flll ant known well croratrue:kin/ntformatoa aniPw.plain the none alike
repair under#21 remarks section or on the back of this farm. 23.Site diagram or additional well details;
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the same constrbction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below load surface: JLi -, go 24a. For Alt Wells: Submit this farm within 30 days of completion of well
For multiple wells list all depths tidlferent(cramp's,-.101200'and 2Ql00') ' ' construction to the following.
10.Static water level below top of easing: WC'` (R.) Division of Water Quality,Information Processing Unit,
If inner level is above casing,use'•+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
r r
11.Borehole diameter. 1�' 1 (in.) 24b.For inledtion Wells: in addition to sending the form to the address in 24a
12.Well construction method: �� � above, also submit a copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,ere_)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center„Raleigh,NC 27699-1636
13a.Yield(gpm) Method of tear i2i ci 24e.for Water Supply&Iniect(on Weil: in addition to sending the form to
the addresses)above, also submit one copy of this form within 30 days of
136 Disinfection type: Amongst: of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

das
Wall Diger Sal1164kostcavilNas
1�
11 I
New
n Kl)d
thereby catttrthe the above referenced well vat grouted in appentsuce accordance%Oh
all CountyWell mies
wren D�i11mr ... A .-�- >_—
Certfikatec 3�, lQ-A - Dale
canetructfx t41011it
Total D -$ D5,_ciang Iraq
Dimmer: LPlg
Height _ _ .
Drive Shoe,. -