GW1--06100_Well Construction - GW1_20230921

I
WELL CONSTRUCTION RECORD For internal rn
This form can be used for single or multiple wells
I.Well Contractor Information: f
14.WATER ZONES
Josh Plemmons FROM 1 TO DESCRIPTION I I
R. ft. I
Well ContractorName
4137-A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for mild.casedwr Ie)OR LiNER(If au Itcable)
FROM TO DIAMETER ; THICKNESS MATERIAL
Clearwater Well Drilling Inc. I IL
a It. (D %f in., pv(�
Company Name 16.INNER CASING OR TUBING(Reothertnal tlmed%(hop)
-7 OM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:U/T- 2Z f' �t-1 (t' ft• in..
Listall applicable well construction permits(Le.County State.Variance etc.) ft. ft. In.'
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: ft. ft. in.
°Agricultural ❑Municipal/Public
ft. ft. in
❑Geothermal(Heating/Cooling Supply) [Residential Water Supply(single)
Olndushial/Commercial °Residential Water Supply(shared) 18.GROil T I.
FROM TO MATERIAL EMPiIACEMENT METEIOD&AMOUNT
/ R. d/) ft. cone& ftl :if C Noo Water Supply Well: ft, t� R. J
❑Monitoring ❑Recovery
injection Well: R. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)'
FROM TO MATERIAL i' I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL R.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING.LOG(striaeaddittonal-sheets If neccOaly)
°Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,{mt. rock type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) rr- R' g'Q R' 8 ot V :.Yl 1 I
01 6-2It. OraJtU ie.
4.Date Well(s)Completed: Well ID# -7 a,R. 5 3 R• C L ( LL
Lisa
Well Location: f 573 EL
Loos-it Tait/ is f',:"h K .''e 7",,.
1 ism SCUTS C-re ©�✓` R. R. `6.-t ,L.,..7 k^ 4-Li
Facility/Owner Name JFacilitylbt#(if applicable) ft. ft. I SEP 2 t_ 2Q2
\e, ft. ft.
Physical Address,City,and Zip 21.REMARKS f tr.t`,;"it aF"'1 For'v"`�4 li
OW'1/41FSOC4
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/agnates/seconds or decimal degrees: 22.C • cation: ;
(if well field,one let/long is sufficient) �r ?� � '
- ` r 4Dt lW:10 N l.) , `�/, )0.1 W / Y- ) 3
Sig ire of Certified Well Contractor Date
6.Is(are)the we0(s):yrternutnent or ❑Temporary signing this Join.1 hereby cant,that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 We!Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or J4io copy of this record has been provided to the well owner.
Ifthis Ls a repair,fill ont known well construction information and explain the nature of the Site diagram or additional well detailSt
repair under#21 remarks section or on the back of this form.
You may use the back of this page to provide ditional well site details or well
S.Number of wells constructed: construction details. You may also attach addtti al pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can SUBMITTAL INSTUCTIONS
submit one form '
9.Total well depth below land surface: • UCT-- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200''and 2®a!00') construction to the following:
10.Static water level below top of casing: —10 (ft.) Division of Water Quality,Informa on Processing Unit,
1617 Mail Service Center,Raleig ,NC 27699-1617
(wafer level is above casing.use"+" 1
11.Borehole diameter: 0 1 (in.) 24b.For Injection Wells: in addition to sendi g 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
(i.e.auger, cable,direct push,etc.) Division of Water Quality,Underground njection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Method of test Center,Raleig ,NC 27699-1636
24c.For Water Sunaly&Injection Wells: in ddition to sending the form to
13a.Yield(gpm) , the address(es) above, also submit one copy this form within 30 days of
Amount completion of well construction to the county ealth department of the county
13b.Disinfection type: where constructed.

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