GW1--06101_Well Construction - GW1_20230921

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons :4.FROMWATER�TO� DESCRIPTION
Well Contractor Name ft. ft. I
4137-A ft. ft. 1
NC Well Contractor Certification Number IS.OUTER CASING(for multi-caaed wells)OR LiNiER(If ap licable)
FROM TO DIAMETER 1 THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft. 4'5 R. L9 I in. 11)
Company Name ` -� �y Q 16.INNER CASING OR TUBING(geothermal 1044-loop) tItATERiAL
2.Well Construction Permit ft: 202 Z7 0�`'q -1 L!"tU EOM TO fL ft.
DIAMETERin.
r
Ess
Lig all applicable well construction permits(i.e.Cmmry.State Variance.sit.) R. ft. iti
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: FROM
p, in.
°Agricultural CMunicipallPublic
°Geothermal(Heating/Cooling Supply) j residential Water Supply(single) H. ill.❑Industrial/Commercial '❑`Residential Water Supply(shared) iL GROUT
FROM TO MATERIAL EA PLACEMENT METHOD&AMOUNT
°irrigation i it. 7a n. Cetlynt- cj
Non-Water Supply Well: R. ft.
°Monitoring °Recovery
Injection Well: it. f.
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable) .
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Storage and Recovery °Salinity Barrier u, f,
°Aquifer Test OStomtwater Drainage it. ft. ;,
[Experimental Technology ❑subsidence Control 20.DRILLING LOG(attach additional sheets If eel:asary)-
OGeothennal(Closed Loop) °Tracer FROM 1TO DESCRIPTION(color.biidams,soil/rock type,main she,ete.)
OGeothennal(Heating/Cooling Return) °Other(explain under RI Remarks) 1C IL 4S H. 6,(a" '6 �'C Yt'd'T
i-e.
4.Date Well(s)Completed: Well 1D# J' , °LVA ft' (lr `
Sa.Well Location:Cedar' en Casbn terG 8 �r ' Ire
H. ft. () , - GENE
_
Facility/Owner Name 'a-3 Facility Mt/(if applicable) ft. ft. 1' - .�_ u rn E E'
CQ60)( \ ,oUe,n R. ft. j'
Physical Address,City,aa Z; y ' 21.REMARKS I � _SEP 2 1 202;
-3-Gerson 1
County Parcel Identification No.(PIN) it rr.n.‘,G"`.....•.�t•1•
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: •
22.Certification. •
(if well field,
one latllang is sufficient) t �,^ I 1 n f„ ,�7-23
��t J I l lS 124, I aSN S Q y'. �W r s 41 i! W �y ((( J
Sigoa�•of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or °Temporary : signing this form.I hereby certify that the we0(s was(mere)constructed in accordance
rah 15A NCAC 02C.0100 or 15A NCAC 02C.0100;Veil Construction Standards and that a
7.Is this a repair to an existing well: °Yes or ,4No copy of this record has been provided to!helm!!own•.
If this is a repair.fill out known well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this form. 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 addi•onal pages if necessary.
For multiple Injection or non-water supply mils ONLY with the same construction.you can
submit oneform. SUBMITTAL INSTUCTIONS j
9.Total well depth below land surface: (ft.) 24a. For Alt Wells: Submit this form w'..in 30 days of completion of well
For multiple wells list all depths Merton(example-3@200'and 2@100') construction to the following:
Division of Water Quality,information Processing Unit,
10.Static water level below top v casing: (ft-) Division
Mail Service Center,Ral igb,NC 27699.1617
Ijun►er level is above casing,use"+'1t 1 oltl
11.Borehole diameter: v (in.) 24b.For Iniection Wells: In addition to se mg the form to the address in 24a
above,also submit a copy of this form wi in 30 days of completion of well
12.Well construction method: rOkald( construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Undergroun Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I 1636 Mail Service Center,Rough,NC 27699-1636
(Li 24c•For Water Supply&1nIectiaIn Wells: addition to sending the form to
Method of testa
13a.Yield(gpm) Gi the address(es) above,also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
Amount:
13b.Disinfection type: where constructed. Ii
Form G q-i North Carolina Department of Environment and Natural Resources—Division of Water+Quality Revised Jan.2013