GW1-2023-01165_Well Construction - GW1_20230126

RECORD l Use ONLY:
WELL CONSTRUCTION REC Forintema
This form can be used for single or multiple wells
1.Well Contractor Information:
NO
Josh Plemmons ps MACF:1itT DESCRIPTION
ft.
Well Contractor Name
4137-A "'
NC Well Connector Certification Number ILO
CASING or maltl rated w�dlt OR L1NeR R
FROM TO DlAlll A THICKNESS MATERIAL
Clearwater Well Drilling Inc. fL In.
Company Name 16.INNER CASING OR TUBING tgeraNl dmed-IM
Sv.� `/ 15
FROM TO DIAMETER in. THICKNESS MATERIAL
2.Well Construction Permit#: _,J fL (L
Lict all applicahle well construction permits(i.e.County.Stare.Foria oe.etc.) It. ft.
3.Well Use(check well use): 17.SCRSI3N
FROM lb DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: ft ft• la.
❑Agricultural ❑MunicipallPublic
❑Geothermal(Heating(Cooling Supply) Residential Water Supply(single)
fL ft. �
❑IndustriaUCommercial ❑Residential Water Supply(shared) Ta GROUT
MWMVUVRL
EMPLACEMENT M HOD A AMOUNT
❑lrri ation Non-Water Supply Well:❑Monitoring ❑Recovery
injection Wen:❑Aquifer Recharge ❑Groundwater Remediation MArERI e TO EMPLACEMENT METHOD
Aquifer Storage and Recovery []Salinity Barrier fL ft,
❑Aquifer Test ❑StormwaterDrainage R. ft•
❑Experimental Technology ❑Subsidence Control 20.DRILI.n_G LOG attaeD#Adidmd theNt N nemury)
OGeothennal(Closed Loop) DTtacer FROM TO DEWMPTTION(plat hardw ..wro`ck a IWO she etc
❑Geothermal(Heating/C ing Return) ]❑Other(explain under#21 Remarks) ft W{ Y
4.Date Well(s)Completed:� ZlWell ID# ft
tt It
Ss.Well Location: tl CO ft \ l AU Af,
�anv IS �^ ' _
J 2 ft. .r °
Facility/Owner Name /'�Facili IDiF(if agtlicabcle)
Phr l Address City,and Zip RK%4Rj(g
N/
2ttjl­
1. r
,�la'1(X�rrl
County Parcel Identification No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 ation•
(iC�wellefield,one lavlong is sufficient) f� 0 lL r tl
V�3 O�s 1 Jo[ U N V I 5 T W V- �� q_—Z�_2
Sig of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By igning this form.I hereLv cerrtfy that the well(s)atts(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consrruction Standards and that a
7.Is this a repair to an existing well: OVes or o copy of thin record has been provided to On-well one.
If this is a repair,fill out known well construction information ariff explain the nature of the
repair under#21 remarks section or on the hack ofthisfarm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply x+elis ONLY with the same construction,vvut can SUBMITTAL iNSTUCTiONS
submit one form. —
9.Total well depth below land surface: O� (ft.) 24a. For AB Wells: Submit this l'omi within 30 days of completion of well
For multiple welts list all depths ifdifferent(example-38200'and 2@1007 construction to the following:
10.Static water level below top of casing: O (M) Division of Water Quality,information Processing Unit,
bf water level is above casing,rise"+"I 1617 Mail Service Center,Raleigh,,NC 27699-1617
11.Borehole diameter: f Q ) (m.) 24b.For Injection Welt: In addition to sending the form to the address in 24a
n 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 Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Suably&Injection Wells: In addition to sending the farm to
the address(es) above• also submit one copy of this form within 30 days of
13b.Disinfection type: Amount completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013