GW1--00629_Well Construction - GW1_20240119

WELL CUNVJ 1 KUL.11Uii KPAAJK1) For InternalUse ONLY: I '
This farm can be used for single or multiple wells
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I.Well Contractor Information:
Josh Plemmons 14 WATERZONES
FROM TO , DESCRIPTION 1
Well ConfnictorName R• R•
4137-A ft• R• 1
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NC Well Contractor Certification Number 15.OUTER CASING.(foamulti-cased wells)OR LINER(ifap ncable)
FROM TO DIAMETER I THI'ICNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft• LQ4 ft: LOI 6-1 ip. PVC
Company Name 16.INNER CASING OR TUBING(geothermal clo)e4-loop)
c� r��3 q -�J%-�I0i ft. ft.FROM TO DIAMETER ! THICKNESS MATERIAL
2.Well Construction Permit* w t1J .� 1 in.
List all applicable well construction permits(i.e.County.State.Variance,etc.) it. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural °Municipal/Public R ft. in. I
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. in. I
❑lndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM ' TTO0 �MAATERRIAL y r IPLACEMENTMETROD&AMOUNT
Non-Water Supply Well: 1 `J`'l 1�0,l �
❑Monitoring ORecovery ft. ft.
Injection Well: ft. ft. , .
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrie[ FROM TO MATERIAL Et1CPLACEtNENTfifETHOD
ft. ft. 1
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
°Experimental Technology °Subsidence Control 1
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardnw,sail/rock type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) ' n- LQa' it. ()( 4-d,('v—i-
4.Date Well(s)Completed: Well ID# � �R, ' ""
ad.f.. � 11-
� R Ge
5a.Well Location: • �J�2t it t n, ilZlI St n5 ft, d
PI Q,h V-Lein, e r '�rq an n. i
Facility/Owner Name Facility IDO(if applicable) .-
ft. it. Jl N 1 g 2024
Physical Address,City,and Zip 21-REMARKS lire. r �4i�.. .
VD \i 10U�1.{et I I c� °CVSO�'�t�:
County Parcel Identification No.(PIN) i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Crtifica- n:
(if well field,one latliong is sufficient) r
t Lk' IS .`1 N a R 3 OD us W
Si of Certified Well Contractor Date
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6.Is(are)the well(s): Prmanent or °Temporary By gning this form,I hereby certify that the.well(s)was(were)constructed in accordance
u h ISA 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 Oo copy of this record has been provided to the mil own .
If this is a repair,ji11 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 toiprovide dditional well site details or well
8.Number of wells constructed: construction details. Yon may also attach addi anal pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction•,you can I
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: KOS (ft.) 24a. For All Wells: Submit this faint'with n 30 days of completion of well
For nndtiple wells list all depths ffdiffirent(example-3Q200'and 2©100') ! construction to the following:
((/)7 '1 (.3L V Division of Water Quality;info lion Processing Unit,
I10.fu Static water level below top of casing: �' (R) 1617 Mail Service Center Ral gh,NC 27699-1617
/jrrnterinel is above casing.use"t I ,
11.Borehole diameter: LQ 0 (in.) 24b.For Infection Wells: In addition to sen ing the form to the address in 24a
Mta,_ r above,also submit a copy of this form)with 30 days of completion of well
12.Well construction method: ��_,{i construction to the following
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Undergoun Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centi r,1 Rale gh,NC 27699-1636
13a.Yield(gpm) I v Method of test: Qii.q24c.For Water Supply&Infection Wells: addition to sending the form to
the addresses)above, also submit one'copy of this form within 30 days of
13b.Disinfection type: Amount completion of well construction to the tour 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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