GW1-2021-04361_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: �t`
Josh Plemmons �� .nti� ' M Rwrl$s TO DrrloN
Well Connector Name
4137 A P r�'t5� ft ft.
NC Well Contractor Certification Number ��O`�� IS.0UTEII CA5ING for multi-eased.welIs OR LINER''if a raahle
Clearwater Well Drilling, Inc. Hot Spring NC 28743 �t1 & TO � DiAME[ER THICIWESS
SS $
Company Name 16.INNER CASING ORTIJBING'.(aeothainal eoaeddoo :-
FROM TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: R fL m,
List all applicable wrll permits(i.e.County,State,Variance,Injection,etc.) ft. ft. ra
3.Well Use(check well use): 17."SCREEN..:
Water Supply Well: 7A&GROUT
TO DIAMETER. StATSI7d THICKNESS MATERIAL
❑Agricultural OMunicipal/Public R' in.
❑Geothermal g Supply) /� Supply(single) ft. in.
(Heatutg/Coolin S 1 udeMial Water S 1 sun e
❑IndustrialtCommercial ❑Residential Water Supply(shared) TO MATERIAL CEMENT BTHOD&AMOUNT
❑Irri lion
Non-Water Supply Wen:
❑Monitoring ❑Recovery
n fL
Injection Well: % &
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PAEK"applicablil,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO MATMATERIALEMPIACEMENTMEIHOD[]Aquifer Test ❑Storm Rwater Drainage R &❑Experimental Technology ❑Subsidence Control
20 DRUJING LOG attach addidouelaheetsif
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION cobr, so0/tock tne.wain shm,eta
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) R ILLID
W- �3-
R R
4.Date Well(s)Completed: Well ID# /1 R R
Sa Well Location: r '1 ,4 11 c�-/ lV ` v
�V tJV� r✓ f4 �
��e �A dS
Facility/OwnerNami—
Facilitv ID#(Q pl�e) N R R
rcal Address.City.and Zip I
0` 21.REMARKS
County Patcel Identification No.(PIN)
5b:Latitude and Longitude in degrees(minutes/seconds or decimal degrees:
(if well field,one Iat/19ng is sufficient) ` 22.Certificati
Q35Rate , 3f Tia~0 v I� 14' W a �
ctor Dam
6.Is(are)the well(s): ermanent or ❑Temporary of Certified Well drdh-
signing this form,I hereby cerr6 that the well(s)was(were)constructed in accordance
�Iwnkenatureqflhe
with 15A NCAC 02C.0100 or 15A NCAC,02CA200 Well Construction Standardr and that a
7.Is this a repair to an existing well: ❑Yes or copy of this record has been provided to the well owner.!#'this is a repair,fill out lotown well construction informationan
repair under 21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
&Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wills ONLY with the same constrac&n,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 4L� (ft) 24a. For An Wens: Submit this form within 30 days of completion of well
For multiple wells list all depths if�erent(example-3 00'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Iniection Wells ONLY: In 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-construction method: construction to the following
(i.e.auger,rotary,cable,direct push,etc.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test2i ' 24c.For Water Supply&Injection Wells:
Also submit one copy of this form I within 30 days of completion of
13b.Disinfection type: Amount o llll construction to the county health department of the county where
Form GW-1 North Carolina Department of Envi onment and Natural Resources-Division of Wamr Resources Revised August 2013