GW1--05786_Well Construction - GW1_20240926

WELL CONSTR JCTION RECORD C.Fox Internal Use ONLY: '
form
n can be used far single or multiple wells
1.Well Contractor Information:
M Or K Al I en 14.WATER ZONES
TROM TO DESCRIPTOR
Weil CoatmctorName rt. ft.
3 Z? -A ft. It.
NC Well Contractor Certification Numbs 1(6 Ot1TSR INO(for rMlcra d e1AISR(if ap�Ueattte
PROM Tr/CAS DIANaT6R* h OR LINER TRtCIrNESa MATCRI)
AL
Clearwater Well Drilling Inc. t ft. 3 ff. % <' In.
Company Name A6.INNER CASING OR TURING c:.::cram
I.Well CewatrucUotl Permit fl: ( D [�0in 10 atR •. D5AM T$R. IL la.
THICKNESS) MATERIAL
List all applicable well construction permits(i.e.Canny,State,Vorianeec etc) — --
n. ft. In.
3.Well Use(cheek well ale): 17,SCASYIV
Water Supply Well: FROM TO DIAMETER l:L(ITSIZE THICKNESS MATERIAL
OAgricultutal OMutlicipal/Public rt h _
❑Geothermal Heati h R b''
/Coolin upply(single)
{ tog g Su pply) Residential Water S
RT
❑IndustriaUCommercial OResidential Water SupplyT
t s(shared) FIR TOAG CI(M6Pti HOD a AMOUNT
Oltrigatioo t F
It. .:),6 R. T ,1i ' ,' �. t\
Noa.water Supply Well:
R. ft.
OMonitoring ORecovery ,
Injection*ell: ft. f.
OAquifer Recharge OGroundwater Resnediation 19.SANO/GpAVEL PA (RlpaheabteL
OA uifer Storageand RecoveryFROM TO MATERIAL EMPLACEMENT METHOD
q L3Satinity Barrier R, rt.
t]AquiferTest t3StortnwaterDrainagea.
—
f7Experimentai Technology OSubsidence Control rt
:Q I:MI %GOO latter additional sheen It necmary)
OOcothertnsl(Closed Loop) °Tracer M yo J seater kardnes,aeiyrvetr aetas� ./
OGeothermal(Heating/Cooling Retum)(J OOther(explain under 421 Remarks) i R. 7�j R. j� ^' V�
4.Date Wells)Completed: U-I 7' 1 Well ID# 71 & akt R '`^N( Q
Sa.Well Location: ail?R •"
�� lA Frc) � �. aft*
K
ft. a
Facility/Owner Name Facility IDN(if applicable)
ft. ft.
�;�e r . ft .mot.>. .0. �._j
Physical City,tad Zip
�{ �y—� zl.REMARKS ' 2024
i- r)�iarWf d v
County Parcel identification No.(PIN)
- ,ram_•1 11ni
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees.
22.
(Werth(Werthfield,one Wong is sufficient) t
13 Lg .11 N �'.a 34 5(9 .Lo W i C4 ),/ _____. -3 -z
Signature efCertified Well Coavac er Date
6.Is(are)the widths): (Perntasent or OTemporary By string s nn,I hereby certify Char hoe Arita)was mr(item)ostrrtcted in accordance with I SA NC firm,
02C.0100 or I S t NC,tC(NC.0200 Well Construction Standards and that a
7.la this a repair to an existing well: OYes or No copy of Mir record has been provided to the,are/I miner.
if this is a repair,fill out known well construction hlfortnarion and explain the nature al'the
repair under 421 remarks section or op the bock 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 injection or non-aster supply wells ONLY with the same construction,you can
submit one Pm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: LIATI (R.) 24a. for AR lyefJg: Submit this form within 30 days of completion of well
For multiple wills list all depths ijdfrrent(crumple-3(/)200•end 2f l60') construction to the following:
10.Static water level below top of casing: Vl C of,) Division of Water Quality,information Processing Unit,
1(rioter level is above casing,use"+" l , 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (.0 (in.) 24n.For Jnleetlsp Wcila: In addition to sending the form to the address in 24a
12.Well construction method: f(��}, , above, also submit a copy of this form within 30 days of completion of well
l!•UC 1 1 construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS g ONLY: 1636 Mall Service Crater.,Raleigh,NC 27699-1636
138.Yield(gpm) Method of test: ./t� 24c•fr'or Willer SUM*&Injection Wrjb; In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
tab.Disinfection type: Amount; completion of well construction to the county health depawucol of the county
where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resnus=-Division of Water Quality Revised Jan./013

Omer New
MO Mew Se*West collecallims
Ihereby certifyibatthe above tektenoed we31 we grouted in o= with
an County Wall Me&
well Dl tJ\CA A IJ " _ l�
cer s &(o Af4 -
Cavaructiar arrant
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