GW1--04862_Well Construction - GW1_20230728

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WELL CONSTRUCTION RECORD
This fan can be used for single or multiple wells For Internal Use ONLY:
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1.Well Contractor Information:
Josh Plemmons 14.WATER ZONES 1
FROM TO DESCRIPTION I
Well Contractor Name ft [4 I
4137-A. ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR MINER(If ap Ruble)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. i ft. -i it. lir i S. in. I PVC,
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
�]j\ � FROM TO DIAMETER THICKNESS MATERIAL
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2.Well Construction Permit#:OSS W-3 °Lo ft. ft. in.
List all applicable well construction permits(Le.County,Stale.Variance,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN I
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R ft. In.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft• ft. in. I
❑Industrial/Conunercial ❑Residential Water Supply(shared) 18.GROUT i
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
t rt. ft. (���
❑Irrigation `u
Non-Water Supply Well:
ft. it.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable) I
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. R.❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft rt.
20.DRILLING LOG(attach additional sheets if necessary).
❑Geothermal(Closed Loop) ❑Tracer FROM 70 DESSCRIPTION color,hardness.s iUroek bue,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) , tI. "Z(( ft- C'/Y l(�a '*1 cu,' _
4.Date Well(s)Completed: Well ID# ZI �"" it. �rC�-V l�
i S`a.Well Location: 3 ad e, CC301-�15 Cil:0 n ft. R. �E.`..�•t n
l.Ltom P,ec LoVe Veo t l ft. it
��(
ft. ft. • t I '4.a 1...a V
Facility/Owner Name Facility ID#(if applicable) ft ft.-1 IS I-tahl' V(PIO 'Tr. N��;1 i Zvi 1.k, ft. ft I ��i!_ " ?fl?3
Physiccal�Addreesss,City.and Zip 21.REMARKS
Pe° te_ o 1 Iflii i�« .+ Ct 4,304siwi*d Uo
id
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifica•ii•,
(if well field,one Int/long is sufficient) to ^3 ,2-3
N W v ✓�
Signs ,of Certified Well Contractor Date
6.Is(are)the well(s):*Permanent or OTemporary B• ring form,orm,I hereby c ertify that the well(s),,ns(were)constructed in accordance
n'i.'I5A NCAC 02C-0100 or ISA NCAC 02C.0200`fell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or O10 copy of this record has been provided to the well owne t
If this 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For nndtiple injection or non-water supply nulls ONLY with the same construction you can
submit oneform. Q _ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: u O� (ft) 24a. For All Wells: Submit this form whom 30 days of completion of well
For multiple wells list all depths ifdiQerent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Quality,information Processing Unit,
If water level is above casing,use"+•'1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: t (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
/� q ,� above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: (/v�"f 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) 37) Method of test i'l 24c.For Water Supply&Injection Wells: In 1ddition 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-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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I hereby am*That the above nferenced well was grated appearance in with
all County Wei rules.
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