GW1-2023-01249_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD r
r Internal Use ONLY:
This form can be used far single or multiple wells
1.Well Contractor information:
Josh Plemmons ; "�TO'tl� DFSCRiPTtDN
WdlCnntraetorNume ft. ft
4137-A ft. fL
U7'ER CA91NG 'O f
NC Well Contrgptvr Certification Number ttltOM TO D1AA 71R TMCKNM MATERIAL
Clearwater Well Drilling Inc. I IL 5D R, Uj`I !n.
Company Name f'&'1NNEIt CA9Ir]C call'I iNG N'btiit>il dotail�tiri"
1�;1 FVOM TO OMMETER THICKKEM MATMAL
2.Well Construction Permit#: � i l/ /J( of th. ft fin.
Listall applicable well construction permits(i.e.County.Stab Variance.air-) ft. p fin.
3.Well Use(check well use): IT
Water Supply Wen: FROM TO DIAMETER BLOTS= TRICKNfiSS MATERIAL
tl, il: In.
[]Agricultural municipal/Public
DGeothermal(HeatinglCooling Supply) �esidential Water�IPiY(single) R'
Dhtdustrial/Commercial OResidential Water Supply(shared) 10.GRotrr
-FROM
TO MATERIAL EMkiACEMENTMEIBDD&AMOUNT
131rri lion R. ft-
Non-Water Supply well: IL
13Monitc ring ❑Recovery >y.
Injection Well:
(]Aquifer Recharge .[]Groundwater Remediation 1.. -yEL PAO ViduffiNNO,
❑Aquifer Storage and Recovery OSalinity Barrier FROM n. To fL MATERIAL KM cEMEKr nasntoD
DAquifer Test OStormwater Drainage
R. R.
[]Experimental Technology []Subsidence Control Zp,DRIiA.NO -7
I ii OGeothermal(Closed Loop) []Tracer FROM DESCIUMON cobs h eft nninek tatase daOGeotilermal eatin Coolie Retum) ❑Other( hlin under#21 Remarks) fft'4,Date Wells)Completed: Well ID# ` b ft iLrt. ft.
5a.Well Location: NO ft. R.
ML
Facility/Owner Name F litylt»I(ifopplicable) R.
OTS @)O-A- -Iaf Vann Rd n M JAN 2 7
Physical Address,City,anA Zip 21
IV
County I Parcel Identification No.(P"
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latilong is sufficient) 22.Cetrti don:
OM' i� .�11P N Ou is t 01 .51A W L — 1D'-7'ZZ
Sign of Certified Well Contractor Date
6.Is(are)thewell(s):wrermanent or OTemporary gy s ;ng t)ris jorm.I hetrlry cehifj that the wrll(s)was(rr�e)catstructed In accordance
wit 15A NCAC 02C.0100 or 15A IYCAC 02C.0200 Wcll Commtction Standards and that a
7.Is this a repair to an existing well: Oyes or C o y ofthis reemd bar heen provided to rhr.well owner.
Ifthiv is a repair,fill can known well construction Itt(brmmlon a `explain the novae ofthe
repair under#21 rcntarAssection or on the bads of thisfarm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Numberof wells Constructed: construction-demils. You may also attach additional pages ifnecessary.
Fnr multiple injection ornon-twrersupply wells ONLFivith the same construction,yrn cart
submit one•1orm. ^7 SUBMITTAL INSTUCTIONS
9 Total well depth below land surface: I tQ� (ft.) 24a. For All Wells: Submit this ibrm within 30 days of completion of well
For multiple welly list all depths ifdfferem(eromple-3@200-mid 2@1001 construction to the following.
10.Slntic water level below top ofeasiog• 100 (ft.) Division of Water Quality,information Processing Unit,
if•waler level k above caving,use"t° 1617 Mall Service Center,Raleigh,NC 276".1617
11,Borehole diameter. ul + (ID.) 24b.)For Injection 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: 71J� construction to the following:
(i.e.auger,rotary,cable,direct push,eta) Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield igpm) d Method oftrst: �t� 24r-For Water Supply&Indi leon ells: In addition to sending the focal to
the addresses)above, also submit one copy of this form within 30 days of
131L Disinfecdon type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Eovimnment and Namrat Resources-Division of WaterQuality Revised Jan.2013
i