GW1--00679_Well Construction - GW1_20240125

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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 14.WATERZONES I
FROM TO DESCRIPTION
Well Contractor Name R. ft.
4137-A ft. R. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if livable)
FROM TO DIAMETER I , THICKNESS I MAT,//L
Clearwater Well Drilling Inc. / It' /,,Q R. , jf,.ia I f, „%
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop) ! �
/� FROM TO DIAMETER, THICKNESS MATERIAL
2.Welt Construction Permit#: V 5 - 20�� 059 ft. ft. ;in. 'I ;
List all applicable well constriction permits(i.e.County,State.Variance,etc.)
R. ft. Lin: 7.e'.
3.Well Use(check well use): 17.SCREEN I
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL, ,
❑Agricultural ❑MunicipallPublic R H. 1°'
❑Geothermal(Heating/Cooling Supply) ) tesidential Water Supply(single) ft. II. in.
Olndustrial/Commercial °Residential Water Supply(shared)- 1&GROUT
FROM TO MATERiAL EMPLACEMENT METHOD&AMOUNT
['Irrigation 1 iL (90 m ern it f '7t f, i�1'Non-Water Supply Well:
R. ft.
['Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACIC(if applicable)
FROM TO MATERIAL' I EhtPLACEMENTMETHOD
❑Aquifer Storage and Recovery OSalinity Barrier
it. ft.
OAquifer Test OStomnvater Drainage
❑Experimental Technology °Subsidence Control ft. ' I
20.DRILLING LOG(attach additional sheets if necessary), •
°Geothermal(Closed Loop) ['Tracer FROM TO DESCRIPTiON(color;curdaess,solYmektype,grata she.eta)
['Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) / D- ! )(p R- sea-)a ek`/..i
e
4.Date Well(s)Completed: Well ID# //� f 4 s � r,,
/(/ .
r o)n. aq7 ft. L e(
5a.Well Location: 40 it. r SH' 51"/V/ �
2020 (y4,/.�o(C( ft. ��: -
Facility/Owner Name Facility ID#(if applicable) R. ft. - i �"�,` a Sr+"
(.S i ,1_�'/.z Rd
Physical Address
City,and Zip 21.REMAR1CS
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/fr/ /�t s/z J
' it riVi lr-ad.t Pr.: 1;2
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certitic n:
(if well field,one latllong is sufficient)ien ra ��jQ /' / �/n A
t 1 t 7(-r(L N F '`3 7 /D -(/ W � A--.----- ' / `�f f/ Gr�
/ Si of Certified Well Contractor has
- Date
6.Is(are)the weil(s): Permanent or ❑Temporary By !going this form.I hereby certify that the uell(s) e (were).tonstructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been provided to the riellorrner
If this is a repair,fill out known well construction information a d rplain the nature of the I
repair tinder#2l remarks section or an the back of this form. 23.Site diagram or additional well details:
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 additional 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: v Jr
(ft.) 24a. For All Wells: Submit this form withi '30 days of completion',. .xveii''
For multiple wells list all depths ifdufferent(example.3(200'and 2®100� construction to the following: ' I - `;
10.Static water level below top of casing: 0° (ft.) Division of Water Quality;inform Lion Processing Unit, ;'
If water level is above casing use"+"(/! 1617 Mail Service Center,?Ralei h,NC 27699-1617
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11.Borehole diameter: (in.) 24b.For inflection Wells: In addition to send g the fonn to the address in 24a
`L/, ,, , above,also submit a copy of this form!with! 30 days of completion of well
12.Well construction method: ID 1 2. UJ construction to the following: - `--1
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(i.e.auger,rotary,cable,(Greet push,etc.) Division of Water Quality,Underground njection Control Program,
FOR WATER SUPPLY WELLS} ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) U Method of test Aq 24e.For Water Supply&Injection Wells: In ddition to sending the form to
the address(es)above,also submit one copy f this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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win Draw SolWawa C•rdlikadon
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Owner:_2‘2.2 .64-eL—' (.(C
Mikan:
Pantt
I bereby cedgytbat the above referenced well was grouted in appearance Inaraxedance with •
ail°minty Wel rules.
Weill:weer J. Timed:
Cerdficate#: / Dato
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Consnurtion: Grout
Rfial Depth; Typdt C4/79,_6(1--/-
Calm oe: SI-ed Thickness: n9//ad
Casing Deptiu/ OP Depth:
Diameter.
Weightfiltdc,---
Drive SSW
GPM:
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