GW1--06281_Well Construction - GW1_20241022

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WELL CONjSTRUC1RON RECORD Fpr internal the ONLY:
This farm caribe used torain&or multiige wells
i.Well Contractor tnformntioa: .
M0rK.At l 140VATERW ; �.
FROM TO DESCRIPTION 1
WellCoatmatorName • le rt. p
32. siO A R. a. I' 1
NC Welt Contractor CettifiaMonManlier _IS�..OUTER CASING(!or n «'de�BR Ceticttt: + s�_ ?-.lelLI ER4Itas ,`,lteabte3
Clearwater Well Drilling Inc. i�' ft. r:tATetuAL .
CoopanyName / ,�) !/ lie%INNSR 0 1RT�/ •- ;• I ; ,� ;,:, � �,
2.Well Censtrueilo*Permit#: i. . '—o()/(/111499(X2 - Cji7,. TO 5AM t� ass MATERIAL
List all applicable nall inutraellan pernNts ft ,Oma Slate,Variaae.etel
R.• tt. in.
3.Wall Use(cheek well use): 17,QCRBEN
Water Supply Well: - - .ram TO 'oaME1 R . sLorsiZS THICKNESS MATE/UAL
DAgricaiitulal ©Manioipal/Public
°Geothermal(Heating/Cooling Supply) °Residential WateeSupply(single) R'� R. •tn: I
❑blustrial/Commerefat °Residential Water Supply(shared) lil.�` I . I - '
pinigationTO .���a � triAc6rM}Rraoao�►![toUals
It D fd-f'Ma-Water ISupply Welk' I f�'Zi
Monitoring °Recovery. R'
O
Injection Well:' it. >a:
QAgoifer Recharge OQroundwater Remediation 10:SENWCJtAYSL PAS naelfettple) ' I '. '
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°Aquifer Storage and Rccove y OSalinity Battier FROM TO MATERIAL' I il11PrACEMENI iNETNob
°Aquifer Test t3Stmmwater Drainage
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Ofixperimeatat'hrlatology L1SnbsidetueCoutrol 1 R UB(atateheddlttonalsheetritnecessary)
❑Geothermal(Closed Loop) 177Yaeer FROM TO DESCRIPTION(Mon b' munoe.kq u;pe w,t�etc.)Dgeothermal(Heating/CoolingRetutn) �OOther(ex0ainunder#21 Remarks) , t ft. 3, ft• -s /1a
4.Date Welke)Completed:Q 5-a(r Welt MN ^i` ��
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weltLomdium (IIlD7 �� 1- ! I .
aI i �f a'fi -gr e - lip s . >�1 .
Fpacccility/ ezcwwne 'f//J D Facility iEW(ifapplieestrle) _ _-
R. ft.
PalAddress,City. d 2;p 2L;l MARKS - ! nil i') `2 207.4
County Parcel ideottfimtian No.(PIN) , f. v ,4 ',�r
r,:,r y,�
Sb.Lattwte ant Longitude le degrees/I/dagter/seconds or decinit l degrees: "
(ifweil field,cm btllong is sufficient) ]2.«� ,;r r n;
gS`379���l�. .N 2.2 .Ol2S2a<<f w i, . -lU��
Sty 0;,-/----.
riifiedWeltContractor pa
6.is(are)the well(s): Permaaent or ❑Temporary may,core, (-) I (low constructed in accordance
BY g this jams,I that the trait jowl
whir lr NCAC 02C.0100 or 1SA NOW 02C.0206 FP Construction Spoke*oral that a
7.Is this a repair to an existing well: Dyes or to ' copy this record has been prawded to tha well ironer.!Phil is a repair,fill oat Loom well construction iafameatioaa explain the mama of the
repair under#21 rermtrkrsection at oft►reb rkefthiejmm. 23.Site diagram or additional well details«
You may use the back of this page to provide additional well site details or well
9.Number of welts censlructedi • censttuctiotidetails. You may also attach additional pages itnrcessar}t
Far multiple infection worm-water sap*wells Olig1'with the same mrutrttetlon,your can
sutan0onafbrm. W. S1JBMITIALINSTUCHIONS 1 `
9.Toat west depth below land suriace: (It:) 24a.For AAR wens: Submit this form•within 0 days of completion of well
For multiple mills listall depths lfeAf erect(ample-38.2110'a 11101 • `., construction tothe following:
10.Static water level below topof easing: OD (D,) Division of Water Quallty,914arma(lotz Processing Unit;
If note level isabore easing two/+" c�^ 1617 Mail Service-Center,Raid NC 276491617
11.Borehole dhimeter. (.#/d (in:} 24b.For-1nlecffmn Wells: 1n addition'to sendin the form to the address in 24a •
above,also submit a copy of this form within 0 days of completion of well
12.-Wel1construction/dethod: ro cttnstmction lathe following:. R
(i.e,auger,naLuy,rabic direct push,eta)
Division of Water Quality,Underground la ectionControl Progrent, '
FOR WATRR SUPPLY WELLS ONLX: 1636 Mae Service Center, ANC 27694--1636
13a.Yield(gpm)_ . g 9 24c.Or waterSunnly BInS .id
on at taste e:glan Wei: 1R on to sending the form to
the addresses)above,also submit one copy of is ism within 30 days of
13b..Disinfection type:' Amount; completion of well conStiuctipn to the county h flit de paMieat of the county
_ whore constructed.
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Form OW-i North Carolina Department of Envtronment and Natant Resources-Division of WehrQualfty Revised lan.2013

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Will WNW Salf-fiweat CoIdicadon
owner: eti-J iokr t/
Addlasz rPennit —
Gva _ poi ��
I hereby certlfytlatt tee above referencedwell was grouted inappearanceiin v
ith
all County Weil rules.
Wed mer: Mark )d/IIM Ste: -�:�y
Cep: 3a�e p G •
Construct on: Grout 1!
Told Depth: TYPE
Cog T V(' Thickness:kneesss: /y fitlQ1 i
Casing Depth: '3 Depth: o?() ! • -I
riameier: 7
W ht/Thidc
Drive Shoe: .
GPM: i
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