GW1--00696_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information: I
Josh Plemmons 14.o WATER ZONES
FROM
DESCRIPTION f
Well Contractor Name ft. ft.
4137-A ft. R. I , I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cesed'wells)OR 1 INER(if ap liable)
FROM TO DIAMETER THICKNESS 1 MATERIAL
Clearwater Well Drilling Inc. / IL (�tk ft. l�72' is I pve
Company Name 16.INNERCASiNG OR TUBING(geothermal closed-loop)
fi13_074g1ln-9�/.29�/ FROM TO DUU1fETER, TN CKNESS MATERIAL
Z.Well Construction Permit II: {J `1' �' J ft. ft. ill. _
List all applicable well construction permits(i.e.County.State,Variance,etc.)
ft. R. I In.
3.Well Use(check well use): 17.SCREEN
1
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R. R. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R' it. in. I
❑Industrial/Commercial OResidential WaterSupply(shared) 1FRO8.GROUT l _
hi TO MATERIAL EMPLACEMENThIEETHOD&AMOUNT
❑Irrigation
/ R. t�D (L ()email- 'I� ,i Lid
Non Water Supply Well:
[Monitoring ❑Recov ft. R.
mY 1
Injection Well: ft. tt.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAYEL PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TD MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control R. IL 1
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer
FROM TO DESCRIPTION(color,hardness,soilhock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) < , fL R. f an7 ,1 , v
tx.4:
4.Date Well(s)Completed: Well ID# T ft. J 77 ft- T�
Sa.Well Location: 57 7 ft. 57 SP- IL ,(/
,err j�
C 7e-ft. &05-ft. � ,4:1e
Facility/O Name Facility ID#(if applicable)era R' ft. JT r i_Q *��
!
ft. fL .-.
��'7J C'Q� ��� ft.. ft. 1 J�IPI N 2 tri 2024
Physical Address,City,and Zip
/'� 21.REMARKS ' 4 ..
` /'Y(//�s Scr/ iit5Vtrr. ' .11 7, y,..; .y,q;3 Leah
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificatip :
(if well`field,one lattfiong is sufficient) (!
3 r!7(.5-t O r 9/ N O r /o ,J I . 9/, w !/L.-�` /O�-7 -2
Si of Certified Well Contractor I Date
6.Is(are)the well(s):Mermanent or ❑Temporary By Igning this form.I hereby cerlfy their the uell(s)i•as(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 11 Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or lIo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this fan,,. 23.Site diagram or additional well details:
You may use the back of this page to provide a ditional well site details or well
8.Number of wells constructed: construction details. You may also attach additio al pages if necessary.
Far multiple injection or non-water supply wells ONLY with the same construction,you can
submit one farm f SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: /,21)S (f.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200''andme 2@100') construction to the following:
10.Static water level below top of casing: tY (IL) Division of Water Quality,Informs'on Processing Unit,
If water level is above casing.use'"+" 1617 Mail Service Center,Raleig ,NC 27699-1617
11.Borehole diameter: lY /e (in.) 246.For Iniection Wells: In addition to send' g the form to the address in 24a
tDft2/ above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground jection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleig�t,NC 27699-1636
13a.Yield(gpm) / Method of test l`�r 24c.For Water Supply StIniectio I Wells: in addition to sending the form to
the address(es) above, also submit one copy o this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county ealth department of the county
where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013