GW1--06211_Well Construction - GW1_20241021

WELL CON 'IcRRJCTION RECORD F,,.internal Use ONLY:
This latmwnbe used farsingte"atnuttipiewalla "
1.Well Contactor fnforn*tion:
Melr1( ki I 141WATSR -
MOM TO MIKT IPTION
Weil Contactor Natne ft. R, I I
32?-w --A n. R I I I -.1,
NC Well Contractor CertifiearbnNomber _a&OtfTERCASIle(for: at'!lt)ORI�iErk a Irbe
tttmRooltMf t0. t)iAMBTBR 7RtC�iN883. jfbf,
Clearwater Well Drilling Inc. ,.,/ '- //� "• (p/$. h- I 1 . ) ye_
CompanyName ft6.u(NER-CA$NC OR79 tc&evtiiernal ctlle4 taop).
47 !/C ..)�ttoM soUw4nTBR mil crass MATERIAL
S.We1lCotistruelI trPfttrmitlh. TJ ft. • iL in. i
• List oil applicable well caastredloa penults(La OM*.,Sate.V rianeu eta)
It.1 it. in. I
3.Well Use(cheek well use): 7.ES
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Water.Supply Well: .l koM [TO , o1AMEU sLOTM Z ' TF imeo SS '7NATENt*L
�Agricuitntal I It • I
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[(Geothmnal(ilei<tinglCoolingSupply) diitesidentiel Watet`SuPP$'( 81e) ft. ft. in. I r
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atndusttial/Commerrcial OResidential Water Supply(shared) trRo>ti_ I
Oltfi tion To ` M¢T£itlldt; srvi.actttw rAlmontt6xtpvNT
Nan•Water Supply VYelit / "tt. ob. ft. �) dLf r17 J f(-1 d '
DMoaitoring CIRecov ft. it.Injection Welt �` ft. ft ` . .
._ I' .
D uifer Recha
rge arge 011oundwater Remediation 193ANING YSL PA WIIP dice bh) I . ,
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°Aquifer Storage and Rosovety t]SalinityBanter yaoM To stATattrAL I Ylti�UcelFtli�trtrenioD
OAtNifttTest O. tic I
t3Siottrrareter Drainage
DlixpetimentalTcbnology f3SubsidenceControl R I- i
i74eotherraell(Closed Loop) DTm r ioiit OC(eemtsltaddntanallett.trtrgt }
PROM To DETCRIPTion(Won tan sellicrktre{strata"e,del
DOeothemtal(Heating/Cooling Return) Dthhcr(txcplainaadar#21 Retna-des): I I R• I/�5 a. )d lye iyf .
4.Date Well(s)Completed:q-10 -2q Weil IlDfl 1�� ik. ` /�Q'�Z i[
well ?PC) �7l R• �/<.f I .
Ott o' . . " . . .M7Tft. Sf qtvoi-€
Faelity/!)Name [E ft. I .`"7 _.>'; ;`;fi.:.' .
Facility iIIA(if .'
ft.
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// City,sad Zip 9 2i. $IVittdtlL4 ,. 0 C T
county I I
pty PamelldeutificatlonNo.(PIN) I Ir. �~
Sb.Latitude and Longitude In degtees/udnntef/seconds or decimal degrees: tion: i , '
(Owen Setd,one latrine is suffiaitat)
353 3) - N . , /Y550/.3w 1(D Y
6.1s(are)the ofCatifled WeltCoteiractor Dune
well(a)s Okermanetlt or CI emporary By signing tits form, hereby cetVP that the IWO-1 (Nero)=mooed in accordancewith 154 NCAC 02C.0100 or 154 NCAC 02C.0200 Wall Construction Standards tmst that a
7.is this a repair ban existing walk Dyes or API° - copy oft*record has beenpraw'ded to the well amtn:
Otis toarepoir,J1l1 out known stall censtructlon lafo matbooanderplointhenahtre(Oka
repair ender1121 remark:section or on thtrbetckafthlsfarm. M.Site diagram or additional Well details;
You may use the back of this page to provide adtl(tfend well site details or will
8.Number of wails cnnt.tntcteds construction details. You may also attach additional pages ifnecessary:
Fortmtltlple irlJedtIongrnon>fw(eryttpp(ysregs fTNE'with the same miutincNotL Yon canI
subunit aaaJbrnt. tttssatlrrrer.rNS[rfCT(otvs
9.Total well depth below ianel surface: c50rs aaa. I'
Foe maklplestrltr list all de the dl ereat example* a 00'and2 l0tP " "' ( ) AQ e� wubmit this form within 30 days of completion of well
P �!/ r �C,T2 � 9 eeastrttation to the following:
I'
10.Static water level below fop of easing: 00 (R•) Division of Water Qualty,lnrorma6sa Processing Unit,
limiter lesrl is ahoy eaning,use"+ ( 1617 Mall Service•Ce�,Raleigh,NC 27699-1617 i
11.Borehole diameter; 0 'S (In.) 24i.1ror lniectitm Welln In addition to sending the form to the address in 24a
12.lVc9ttroastroctioa fnethod: rD L/b r„ i above,also submit a copy of this form within 30 days of completion of well
�'�(J cOnstnuctfon Mille fallowing:. II
(i.e.auger,ratery,cables directptubr etc.) -
Dtvisfon of Water Quality,Undergrotmd Injection Control Program,
MR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
7
13s.Yield(gym) Method of tuft / )/�jli
•liar Water Sanely&1nlec*lon Wells: le addition to sending the form to
I • -Ma addrets(es)above,also submit one copy of Shia form Within 30 days of
I3b Disinfection type; Atnouok completion of well construction to die I aunty health depampeot of the county
where constructed.
Form 0W-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality l
Revisedlm.2013
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