GW1--00599_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: 1
14.WATER ZONES I i
Josh Plemmons FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4137-A ft. ft.
NC Well Contractor Certification Number - 15.OUTER CASING(for multi-cased welts)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. / R. /0/ ft. /0/tin. f)Uk'3Company Name -16.INNER CASING OR TUBING(geothermal closed-loop)
„n� 00
� f//� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: U("//� O/IILO B• R• fn
List all applicable well construction permits(i.e.County.State.Variance,etc.) R. ft. in.
3.Well Use(check well use): 17.SCREEN i
Water Supply Well: FROM TO DIAMETER SLOTSIZEI THICKNESS MATERIAL
ft. It. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Aesidential Water Supply(single) ft. it. in.
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation / IL of s��l f. /17 merit /vd
Non-Water Supply Well: ft. tl ft. r /�/
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge IJGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable) I
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL R.
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hsirdness,solUrock type.main size,etc.) -
❑Geothetmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) l/ ft• /0/ R• Sa �a -k 4-
4.Date Well(s)Completed: Well ID# " O/ ' (a-7 7 R 1 016
077 ft. C078'ft. U
5a.Well Location: &7C
ft. ft.
paiuie
)nri s Ann Geer ft. ft. - I —':;— ��
Facility/Owner Name Facility ID#(if applicable) - L y a t rutty a.
395 f luQ.inP.�� � r�. ft. �. I JAN 1 .8 2024
ysical Address,City,and Zip 21.REMARKS
nR1 tt7 1 �}
(�, WOOYYN VII iL�i`(/-/ of 1 rn. !�
County Parcel Identification No.(PIN) I,/yb -`J
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certitic 'on:
(if well field,one lat/long is sufficient)
Si o edified Well Contractor . Date
6.Is(are)the well(s): Permanent or ❑Temporary signing this form,I hereby cent&that the wells) vas(were)constructed in accordance
with 15A NCAC 02C.0100 or 154 NCAC 02C.0200 ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or . No copy of this record has been provided to the well oust
If this is a repair,fill out known well construction information and explain the nature of the I,
repair under#21 remarks section or on the back alibis fonn. 23.Site diagram or additional well details:
You may use the back of this page to provide dditional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply nulls ONLY with the same construction,you can submit one form. SUBMITTAL INSTUCTIONS 9.Total well depth below land surface: —I 45 (ft:) 24a. For All Wells: Submit this form withi 30 days of completion of well
Far multiple wells list all depths(fd erent(example-3 tr•200'and 2(ja l00) construction to the following:
1 Division of Water Quality,Inform lion Processing Unit,
10.Static water level below top of casing: W (ft.) 1 i
If water level is above casing,use"+"t 1617 Mail Service CI nter,Ralei h,NC 27699-1617
11.Borehole diameter: 10 I 0 (in) 24b.For Infection Wells: In addition to send ng the form to the address in 24a
//��, above,also submit a copy of this'form withi 30 days of completion of well
12.Well construction method: ro4(A NI construction to the following: i
(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 Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
(gpm) the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction t i the county health department of the county
where constructed.
Form ow-1 North Carolina Department ofEnvironment and Natural Resources—Division of Water Quality Revised Jan.2013