GW1--06326_Well Construction - GW1_20241022

WE L CONSTRPCTION RECORD
• 77risimmcaaibeasediars For[ntecn�l(Ise ONLY:
•
(ogle Or matBpte wells
1.Well Contractor Infortmitioa: _,,,,_.,, ,� __
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N1t�rK . 11 1 'N y1& IM • Tot1ESCRteTrO1,l
Wel1ComraetorName 'ft, rt. I 1
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NC Weit Contractor @etiEfieationNember g.uneoi T igiy G rfbr: ND/kAMvier4$;cast. UEt .p ) t
Clearwater Well Drilling Inc. t 7�5. R. ( `1 c'n I ve
CompennName ��/��(y liffi INN5R�QR!UB?JG(QealileritudeltuutItun)
i(911 f 9 5'-' 0 V U ( . ("rd M innitt tilt TNtt0NESS MA7ERiili.
Z.Weld Conatrtiadiaf►Per,Ditll: O. y), in,
- List all applicable welleOuttruction pawns(Le,Cormlp.State,Y4riancva eft)
3.Welt Use(check well Die): it iRCft!>glli ,
Water Supply Welt: . .vttOM� TO . . "DIAMETER 5LOTSiZE ) 7lli1CKNRSti - MAreaLL , [
°Agricultural DM4ionioipnlfPublic -
❑Geothetmal(HeathsglCooling Supply) Residential WatetSuppty(single) ft' R'; . .
[]IndutatiallCotmua rciat C1Reslderttiel Water Supply(shared)
❑ ttort 'TO mum..e _ �fiMt3Qtr)<!(i'rtt ns&MOUNT
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N titer Supply We11:
❑Monitoring. . ORecovery L rt. !,
Injection Weft- A. ' f. !.
f7Agnifer Recharge ❑Groundwater Remediatfon St:SANitlRtAVXLPA of adit�t3Le) . ( . ' ,
ClAqulfcr Storage and Recovery t]Salinity Banter Rost rt.. ToItete trlt[@LICElIr6NptiefiTttgD I` .
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OAyulldrTest ©StonnwaterDrainage . _
I3tsxperimenta1Thdmmlogy CiSDbsidenceControl rt. �'
tJGeotltertDatl(ClosedEAop} Wrote:. A llitilUNGLOD(titit trtddinonilikeenirxeiastpari :
FROM TO DSSC�tt!noft Leiter tan seiNacktor,j train skg da) '
,❑Qeothermal(Hc ating/Cooling Rctum) OOther(esplainundcr#21 Remattks). l ft. 35 tl• - Ea Q +dR r+- - -
4.Date Welt(s)ebn►pr'l'e� weu rolf5 Jra, S }$ ,
WeilLoeztlnn: ft. ft. ,'`
/'HIV tr. u .,! 2024
Fecility�Natne Malty LIM(ifoppGeebfe) -
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3aE �,1tne rcI WI P ltt,ot�
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P 1 Aatdieaa,City.wed Zip . f �' I DI,t:u` i;y,.; I- 'i4
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County Parcel wentifiatiam No.(PIN) I
Sb.Latitude she Longitude in degree3/ndnttes/seconds or decitsal degrees: 22 bons(if well field,one haloes is sufficient)
y-4115aDN ? ' © O5D w . .- ' -/ q -area
Sian• •ofCertified Welt r
6.Is(are)the Deign): ertmanent or ❑Temporlary sign j Dale
By g this.form,I hereby a:ero'shut the Wilk.)uric(here)constructed in oecardmnce
Kith l NCACO2C.0100 or 1SA NCICOIC.0280 Weil Cbnstrec:ion Senatordsend that a
7.is this a repair to en existing well: ❑Ves or Xio • copy ofthis record has besot provided maim!!atom
Ohl,Ita mak fill mrtinowr:well construction lefarmmlon anti exploits thenature arhe t
repair under#21remailtreecttan or on the baetojthltfi m. 2R.Site diagram oradditional well detalls:
You may use the hack of this page to provide additional well site details or well
S.Number of welts constructed: construction details. You may also attach additionals pages i£m ery; •
For multiple injection groan-meter sup*mils Mil'with the tante construedoa.you can ;
submit one �O SUBMITTAL INSTUCTIONS
9.Total west depth below bed surface: (fb) 2.1n.For Ai("Miss Submit this shirts within 30 days of completion of well
For toubbsle wvJ arson depths ij'd ere t eewmpte.3000•aaed26007 construction to the following: i
..
10.Stink water level below topofeasing: 0 ((t,) Division of Water Quality,iatonn.a n Pracesving Unit,
renter level isabbee easing,use"+"1�S.
1617 Mail Service.Center,Ra NC 276994617
i I.Borehole diameter. _La On.) 24ta.For•Iolectfnp Well 3n addition to sandhi the form to the address in 24a
above,also submit a copy of this form within 0 days of completion of well
2.We8tonstruction Metitatit roiraiu atsuuctionto-thefallowing i' ,
(i.e.auger,retain cable,dims push,axe.) E
Division of Water Quality,Unde tgramnd Injecfont oniro[Program,
FOR WATER SUPPLY .2 WELLS ONLY: 1636 Mail Service Center, ,INC 27699-1636
130.Yield(gpn) 9 Method of taut ( 24c.;For Water Sonniv&Jniectini, veils: tp addition to sending the fomn to
- 'the addresses)above,also unbolt(Mel copy of}his from within 30 days of
completion of I3h,Disinfection type: Amount; _ where constractaxi?l corestntetIaln to tin county ice ith department of the county
i .
Fotnt OW-I NorthCataniaDepartment otEnvironmanr and Natural Resources—Division of Water
QaOitYl Revised Ian.28t3
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