GW1--06283_Well Construction - GW1_20241022

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WELL CONSTRUCTION RECORD ruse Internal vie ONLY: .
This dorm caribe used fin-single er nmltiple avells
1.We
ltt Contractor Informa llo n:
" d Y \ e at ATBRZONESI •
MOM
,70 . DESO DESORPTION
Well ContraclorName R. (t I 1
aZ,?tty -A R. I
NC Weil CoutateorCettifcatlonNumba �8.. U�U'193RCA9EN1li(lhr.Tiliknesidatilt). RLil ;if"a ' jxxoatro. zstt Txtetrnsas hsAr�tf,:,t,
Clearwater Well Drilling inc. j R. i DO ft. Lav` ;In. I Nc,
ComnenyNanie 14.lNNER-CAS1NOQRT Gf ratafdint4-todpj
. i(g�+ �� s -. >+rAseRtAc2.Well Construction Parndt0: cn tY. to •
• List onapplkable mllctlnstriictloh p�mlls(La Canrny, te,Varirmea ale) tt. f4 in.
3.Well Use(cheek well use): 17.
Water Supply Well: SCREEN:Rs1" '-DIAMETER amoral? 1 'kltICENESS 'MATERIAL '
OAgriculttuat CiMuniaipaUPublio ft. f • tn.
°Geothermal(Ileitttng1CootingSupply) [residential WatetSupply(singte) R• ft. . in.
Clindusttial/Commetclai °Residential Water Supply(shared) , i '
Olrrigation "K'r'a+ 7R MATERIAL iPlN�i/LAcctal rPaitattOnAARtvittir ,
Non-Witter Supply Wells ft. . n. �[.t� 4 Y 1 1 .Q d
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°Monitoring . °Recovery. . I
Injection Well: R.• L. I .
OAgtdfer Recharge DGreenndwater Ranediation a;ti:ANAIGpt L-PA, ' auon4Dle) ' I
°7Aquifer Storage and Recovery aSaHnity Bauder Paolam EflM t ii►�twPEatfiNt aRlirt[OD
°AquifearTest t3StounwaterDrainage .. I -
ft..OExperimentidTechnology COSubsidenceControl
Otjeothermal(Closed •1 pillllNGWOEatt htaiditlonetitleets.treectssurj _
Loop) Macer ,W ORR 10 DESCRttUON(alor.haidam,srll eek
.t]Geothermal(Heating:Cooling Ream) ClOther(expiainundeu-#21 Rematis). tR R. i �'t°ram' 1
(� ( �(� �/ .�1 `fir riff
Date Welke)Completed:` 1 ' qWeU[Dip �A(iLY c `ook ' (� rr' nn
3a.Watt I.ocar6an: 4
0 R. 1i05' 11.t
Facility/owner lOwnerName dY ( applicable) I '� �'._' I. , '•' ^.., _
N Each' if►A ifs li ff. �
551E (11 re en Qd , rd1Of. �. O T 2 2 2021 - .
P real Address,City. d zip
.� I I lQ.� r� RA:RSIP1AItI(9 t; �... _^ -, 1 i.,,�
County Parcel identification No.(PIN)
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Sit.Latitude and Longitude is degreeatminhteslaecunds or decimal degrees:
(if well Geld,one lading is sufficient) 22-C
. o f 35 - .N sit DI
4-1 '' W ) z
,I q -44(1 •
:
Signatures CetifiedWeiContractor ip
6.is(are)thewdt(a): Permanent or 1]Tentpt►trary ay signing this form.r bareby corms•arat 6Wits)i there)cunseuaed in arc
ordance ,
Kali ISA NC4C 02C.0IWD or ISA 11Cac a2C.0200 Weil Con ruction Slatrrfandr and that a
7.Is this a repair to an existing well: °Yes or kiio - copy titbit record has beorprmddd tatheiwell m aw.
phis Ls arepalr.J11J ant knowitell construction infoatnmlou and wick the nature r flhe `
repair wider 021 remark-section or on the bockvfthis fa nr. 23.Site diagram or additional well detalls:
You may use the hack of this page tti provide ad 1 well site details or well
S.Number of wells constraetedi censtmetioladetails. You mayaksoan*additionel pages ifnecessary.
Far multiple laWIanernon4 tatersupp(p nuijr ONLY with Magma aanrinsail n,you can
sulaml oeafbrm. �r SI.IUMi7TAL INSrUCTIONS l'
9.Total well depth below land surfacer "� •
(IL) 24a.•J?r AQ v .fig: Submit this Torn within 0 days of completion of well '
For smblpl,incite list nil*prig ORPtsetti(emnrpte•302OO''aetd2@ttl0') ' construction to the following.
10 Static water level below top-of easing. L.0 0 _(if.) Division of Water Quality,Informillonr Processing Unit.
If Raterlevel Is above cm/ng,use",+- 1617 Mall ServiceCenter',Ratdgb NC 27699.1617
11.Borehole diameter: lY 1 I i' SI i
Om) 24h.}tier Inlldiop We l= 3n addition to sendio the form to the address in 24a ;
above,also submit a copy of this form within 0 days of completion of well
12.1Veltconstruction.4hod: r[ icti ui cgnstmction bathe Mint/Amp. I
(Le.anger,Mary,cable,direct push,ate.)
Ridden of Water Quality,Underground In eclionControl Program,
FOR WATER SUPPLY WELLS ONLVV QN161
t�6 Mon Service Cen r,Rale NC 27699.163613a.Yield(gpn* . 1 Method of teat: Zoe.Par Water S3tn1&&lnt�ltrn Wells: 1 Wa�ition to sending the form to
the addresses)abate.also submit ono copy of;his form within 30 days of
136..DMntltetion type; Atttortttt; completion of well contraction to Ilk county health department of the county
where constructed. f
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Form OW-1 Werth Carolina Department of Environment and Natural Resources-Divbien of Water Quality Revised kn.2013
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