GW1--06106_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: ,
I4.WATER ZONES I I
Josh Plemmons FROM TO DESCRIPTION.
Well Contractor Name R. it
4137-A ft. ft. I
15.OUTER CASING(for mull-cased vidls)OR LINER(If ap ticable) •
NC Well Contractor Certification Number • FROM TO DIAMETER ! THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft. 103 ft. (s '\ in. PVC
Company Name 1‘INNER CASING OR TUBING(geothermalclosbd-loop) -
j rr++ff//���/�n, FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ft:2O�— ZY^I(J(9-Q 19Lo It. it. in.
List all applicable well construction permits(Le.County.State.Variance,etc.) ft ft in,
i.
3.Well Use(check well use): 17.SCREEN ;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: ft ft. in.
❑Agricultural ❑Municipal/Public
il. n. in.
❑Geothemmal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑lndustriaVCommeiuial ❑Residential Water Supply(shared) I&GROUTM FRO TO MATERIAL En PLACEMENTTJMETROD&AMOUNT
❑Irrigation ` tt. 20 ft `'r Zvi Y , `o(nk- ti 1
Non-Water Supply Well: R. ft. -
❑Monitoring ❑Recovery
Injection Well: .
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier rt. ft. I
OAquiferTest ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑5ubsidenceComrol 20.DRILLING.LOG(attach ddItIOahI sheets if necessary).
❑Geothermal(Closed Loop) ❑Tracer FRROM TO DESCRIPTION
�(color,`hlkrdness,soiVmcktope,Ervin size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) A--
La-5I R• tt(``;15 ft. SA �Ct 4i cif
ft T,V ft rlJl.l i
4.Date Well(s)Completed: Well ID# t,--if11t l,� I tt
5a.Well Location: `14-11 D• H. TO,VIA 4e
CoshiffsY 1 1 l0 - RC ft. ft f-. .,.. , r rof
Facility/Owner Name Facility IDi/(if applicable) ft f. t Z, , ,r i V c, "
lbOt flash poil14 Dr. ft. ft. s{� 2023
Peoiiccat Address, ty City,and Zip 21.REMARKS
J( es ! I ate i..1 2,:-., . 3 lit-;r
County Parcel Identification No,(PIN) D 1Q SSG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certi r ation:
Orwell field,one Int/long is sufficient)
• I o °- a,q N 7 ' 0 " 5a . W /,...,._— -a 3
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Si„,tureof Certified Well Contractor i Date
6.Is(are)the well(s):Yitermanent or ❑Temporary : signing this form.I hereby tern&that the well(s was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200Well Construction Standards and that a
copyof this record has been provided loathe xellotrmr-
7.Is this a repair to an existing well: ❑Yes or �To
If this is amen-Jill out known well construction information and explain the nature of the i
•Site diagram or additional well details:
repair under WI 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-ureter supply wells ONLY with tiresome construction you can SUBMITTAL)1VSTUCTIONS I
submit one form. (fie
9.Total well depth below land surface: 5`J J (It) 24a. For All Wells: Submit this form wi in 30 days of completion of well
For multiple wells list o0 depths if different(example-3C200'and 2®100) construction to the.following:
1Division of Water Quality,Infor ation Processing Unit,
I wtr Staticv water level below top of casing: (ft) 1617 Mall Service Center,Ralf-gb,NC 27699-1617
If water level is above casing,usef"+1
11.Borehole diameter: VI I O (in.) 24b.For Injection Wells: In addition to s ding 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: np+an-1( construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Undergrou d Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Rat igh,NC 27699-1636
Method of test (` 24e.For Water Supply&Infection Wells: n addition to sending the form to
13a.Yield(gpm) y the address(es) above, also submitl one cop of this form within 30 days of
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Amount: completion of well construction'to the coon health department of the county
13b.Disinfection type: where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan-2013