GW1--01753_Well Construction - GW1_20240320

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells Fur Internal Use ONLY:
1.Well Contractor Information:
Josh Plemmons 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft ft.
4137-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft. ft. -
Company Name _ 16.INNER CASING OR TUBING(geothermal closed-loop)
} I�- ��0��/1/ , FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: V1V! 0Ca ft. It. in.
List all applicable well construction permits(i.e.County.Slate.Variance.etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER nor SIZE THICKNESS MATERIAL
❑A cultural ft. ft. In.
Sri ❑MunicipaUPublic ^
eothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) H, ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation It. ft.
Non-Water Supply Well:
-
ft. ft.
❑Monitoti ng ❑Recovery
Injection Well: It. n.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROat TO MATERIAL I EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
-
ft. ft.
❑Experimental Technology ❑Subsidence Control _
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTIONjcolor,hudness,soNroc type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)_. r ft. . rt. /,( 0.LL-e��
4.Date Well(s)Completed: Well ID# ft. IL �n_ .S 4J7
ft. ft.
5a.Well Location: i
(e(- �- C ►�s -ti(chts ft. --. -
Facility/OwnerIName J Facility ID#(if aA-rr,Li.n
licable) ft. ft.
�...�.•`
L-03 W&xu* '&11t; )(LLB n. ft. gA'R ° 9-2Q24
P sisal Address,City,and Zip
1.REMARKS
er 2
.Lp cern ✓Li -4-43:.xra�; 24.r�\up.."
County Parcel identification No.(PiN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certitic: .
(if well field,one lat/long is sufficient)
a5*O 51,CI1 N Ba' st 4 4-.(JO W a7 ail
Sign. .1, of Certified Well Contractor Date
6.Is(are)the well(s): `Permanent or OTemporary By going this form. 1 hereby certifJ•that the we//(s)was(were)constructed in accordance
wi't iSA 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 )4No copy of this record has been provided to the well miner.
1/this is a repair,fill out known well construction information a d esplain the nature of the
repair under#21 remarks section or on the back of this fors. 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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft,) 24a. For AU Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifOfferettt(example-3(a-200'and 2tu;100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,information Processing Unit,
If water leeel is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this firm within 30 days of completion of well
12.Well construction method: construction to the following: 1
(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(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county 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