GW1-2023-01261_Well Construction - GW1_20230126

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons FRO M TER TO DESCR1M70N
Well Contractor Name ft. ft.
4137-A rt n
NC Well Contractor Certification Number 15.OUTER CASING for matt-eased wtis OR LINER ble
FROM TO DIAMETE THICKNESS MATERIAL
Clearwater Well Drilling Inc. i ft. R '� in.
Company Name _ 16 INNER CASING OR TUBING r1na1 daaed 1
(�j� ('� FROM TO DIAMETER 'litICKNESS MATERIAL
2.Well Construction Permit#; t"�`^' y• 1 f s-'` C4 v R R to
List all applicable well construction permits(i.e.County.State.Variance.etc.) In.
3.Well Use(check well use): 17.SCREEN
FROM TO D1AMtTaR SLOT 917i 14rICKNF34 MATFJt1AL
Water Supply Well:
R. rL in.
❑Agricultural ❑MunicipaUPublic
s fl fti to
[]Geothermal(Heating/Cooling/Coolin Supply) Aeidential Water SuPPiY(single)
❑IndustriaKommercial ❑Residential Water Supply(shared) FROM TO MATERIAL ElellLALTMEMr MBTBOD a AMOUNT
Oirrigation R• IL \
Non-Water Supply Well:
R. R.
❑Monitoring ❑Recovery
injection Well:
❑Aquifer Recharge OGroundwater Remediation if.&4MMMAYEL PACK
FROM TO MA79i:RiAl. aMPLACEMLNT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft R.
❑Aquifer Test ❑Stormwater Drainage R It.
❑Experimental Technology []Subsidence Control
20.DRILLING LOG faltatib addltload shetw If❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRiMON plan lairdaess,satlf—k tym Vain Site,tic.
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks R' R
R. �,(��R.
4.Date Well(a)Completed: _Well ID# r v � ft-
\ q
5s.Well Location:
Facility/Owner Name Facility lD9(ifapplicable) R
P ical Address,City,and Zip 21.REMARKS
�- rd
County Parcel Identification No.(PiN)
d ees Sb.Latitude and Longitude in de minuteslsetonda or decimal
°b`i Bra � 22.Ceres
(ifwell field,one l�atilong is sufficient) J lQ %,ILO f
N l`JU� �J , IJD W G
Sign 14ofCcrtifierIVIcliContnactor Daft
6.Is(are)the well(s): ermanent or ❑Temporary By s 2ning this form.I herehv terrify that the wells)war(arere)romtrurted in accordance
with I SA NCAC 02C.0100 or I SA NCAC o2C.o200 Wd/Construction Standruds and that a
7.is this a repair to an existing well: []Yes or fy� - copy of this record bas been provided to the well owner.
!f this is a repair,fill oru known well construction information and explain the name of the
repair under#21 remarks section or an the hater r f rhk faun.
23_Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
9.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-twier supply tells ONLY with the amne constrnedan,ytm can
submitoneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: —I. � (ft) 24a. For AN Welts: Submit this form within 30 days of completion of well
For multiple wells fist all depths ifdlfferent(example-3(aj200'am11@100') construction to the following:
10.Static water level below top of casing. (R-) Division of Water Quality,information Processing Unit,
if water level is above casing.use"+" I 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
l ) above, also submit a copy of this form within 30 days of completion of well
nV 12.Well construction method: l r o "L( 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 Supply Br Iniecdon Wells: <n addition to sending the firm 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