GW1-2023-01183_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons 14,wATER.zorm
FROM TO DESCRIPTION
Well Contractor Name ft. R j
4137 A IL It.
NC Well Contractor Cor ification Number 15.OUTER CASING for aid-a"wells)ORLiNER Man bte
FROM I TO DIAMETER ITHICKNESS MATERIAL
Clearwater Well Drilling Inc. I ft. rg� ItI ta%
Company Namc lb.INNER CASING OR TUBING footiltetdtiel eloee&IM
FROM TO DIAMETER I THICItNM I MATERIAL
2.Well Construction Permit#: IL ft. in
List all applicable well construction permits(i.e.County.State Variance,etc.) it ft. is
3,Well Use(check well use): 17.SCRVEN
Water Supply Wen: FROM TO DtAMET' SLOT SIZE THICKNESS MATERIAL
H, ft. In In.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri lion R, R, 0JL
MOV
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Weil: fl. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK Of smIlledle)
FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier a,
❑Aquifer Test ❑Stormwater Drainage
R IL
ft.
[]Experimental Technology []Subsidence Control 20.DRILLING LOG fattkah additional iiheatrif neeessa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION r ba 80flt ek a Ia ere
❑Geothermal Hesting/Coolin Return) ❑Other(explain under#21 Remarks) n 1
ft. `ft I
4,Date Well(s)Completed: Well ID# t ft
(4* 15V ay
Sa.Well Location: fn ft. I�� � ,-�i�p_o t ,F;'
ls� lk-
Facili /Owner Name Facility ID#(if applicable) H R, J A N
' +FR I*—� ,erns-\A I L �JG It. It.
Physical Address,City,and Zip
^� 21.REMARKS !tlioirj,:a,:.,:. Q i.�.
Coun Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certiflca'on:
(ifwell field.gone lat/long is sufficient)IS V
Sig7-'15'Af411'NVCAC
of Certified Well Contractor Date
6.Is(are)the well(s):�ermanet t or ❑Temporary
Bythisform.Iherehvcertifythat the wefl(s)was(were)ronstrvMedin occordouce
02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: []Yes or KNO espy ofthis record has been provided to the well owner.
flthis is a repair,fill out known well construction information and explain the nature of the
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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-watersupp/y well;ONLY with the some construction,Jwm can
submitoneform. /� SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1 "�t� A) 24a. For All Wells: Submit this fbtm within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3@200-and 2@100') construction to the following:
10.Static water level below top of casing: (0,✓ (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,rise""+" 1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. Q (in,) 24b.For iniection Wells: 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: )(i(, construction to the following:
(i.e.anger,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
13s.Vield(gpm) fO Method of test:A t 24c.For Water Suni ly&Infection Wells: In addition to sending the form 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-1 North Carolina Department of Environment and Natural Resources—Division of Water li
Qua tY Revised Jan.2013