GW1--05807_Well Construction - GW1_20240926

•
WELL CONSTRUCTION RECORD 4bnsanni Use ONLY:
This form can be used for single or multiple welts •
I.Well Contractor information: - c :-
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Well Contractor Name
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NC Well Contractor Certification Number FAoM To ' DtAMETQi TNfCKNUS N1i►TPdtrAL
Clearwater Well Drilling Inc. / h. 3; "- / ? �iit;)(t./1 SfyQ/
Compsrry Name
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//� �/ {p i1tAMkT rHICKNICSS 1MAf .
(/1�OI t!L) / FRt11M is.
2.Well Construction Permit#: ft. _
List all applicable well construction permits(Le.County,State.Variance.etc.) R. R. In ,
3.Well Use(check well use): J7.OCIUMtlf .. ;
-Water Supply Well: FROM To MAlMtLf�it sldtl� �iIA'1}�A4
ft, tL tn.
°Agricultural °Municipal/Public I — .
h, f, in.
CGeothcrmal(Heating/Cooling Supply) residential Water Supply(single)
❑IndushisUCommerr ial °Residential Water Supply(shared) I8"H °ROB - *,ttttIMPIT 1.
*moatLD Mi}r>kMAL I�GMt!4 r r
°litigation ^ 1 ft. t270 ft.
,eel-re/if i xC
Non-Water Supply Welt: ", it.
°Monitoring ❑Recovery
h, rt. .
injection Well: ._
°Aquifer Recharge OGroundwater Remedialion .t9.SAND/G>i 481114' (f o#flaid - --
FRoaI TO MATERIALf:Mvt.wCEMENT MHTHOD
CoAquifer Storage and Recovery °Salinity Ranier ft, ft,
°Aquifer Test OStormwater Drainage f4 "
C°ExperimentalTechnology 1GSubsideneeControl llifaillARIC4 .f ,.idditiopal;heatsitpets trey).._
°Geothermal(Closed Loop) ()Tracer , 'Rost TOr PfsewliyMo)N�(eater.bard aen�seiVrtek type Vag slut rut,}
❑Geothermal(Heating/Coolingg Return). ()°titer(explain under#21 Bernath) / D p{ p' S 1 Y� �f
4.Date Well(s)Completed: O OC/ ��NYell UM �/ �/q " Z7�
•��77 a /f Sa.Well Location: ..- L `/d/9lft t /7sf. 1.1. 1J J r .
li/&.rr I) .-Pease /ru S 7 R. {v R. rG'_ .
{'FaaciliFty/Owner Nate // pi acility1 (if applicable)
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�J`'J r put)Pam! /�v�-/� �GN-di-t ilC.G R. !G •,•I►.. 0.�..
Ph Address.�,�lp :�:1trr -S E R.2.:u,.. 021,
County Parcel identification No.(PIN) (Y ii t: • 'Pit
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Car anon:
(if well field,one lat/long is sufficient)
3 ' 4f-3 31 S N Ya .�� � 1.1Y� W Cam- 3 �
Signature of Certified Well Contractor Date
6.is(are)the well(s): termanent or °Temporary
By signing this form.I hereby cerlfr that the nell(s)nes(were)constructed in accordance
�� with I SA NCAC 02C.0100 or/SA NCAC 02C.0260 Well Construction Standard,and that a
7.is this a repair to an existing well: ❑Yes or J(JNo copy of this record has been provided to the well owner.
Ifth(s is a repair,fill our kn ,,ow well construction information rplain the nature of the
repair under#21 remarks section or an the back of this'brio. 23.Site diagram or additional well details:
You 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 Infection or non-winter supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 705 (rL) 24a. For AR Wells- Submit this form within 30 days of completion of wall
For multiple wells liste!!depths Ifdifferent(example-3@200'and 20100) construction to the following:
10.Static water level below top of casing: 690 (fL) Division of Water Quality,Information PruCtasiag Unit,
If testier level ie above.casing,rise"+. 0
y2 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ( � o (in.) 24b.For Infection Wells: 1n addition to sending the form to the address in 24a
above, also submit a copy of this. form within 30 days of completion of well
12.Well eonatruetion methods YU t construction to the following:
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY /W..��ELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) <5 Method of test•. t6q 24c.For Water.Suuoly&In(ectiell;Wells; fit►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 department of the county
where constructed.
Form OW-1 North Carolina Department of Environment and Natural Reaomces-Division of Water Quality
Revised Jan.201 3

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