GW1--02270_Well Construction - GW1_20240409

I
WELL CONSTRUCTION RECORD
This farm can be used for single or multiple wells J
For Internal Use ONLY:
1.Well Contractor Information: I
Josh Plemmons 14.WATER ZONES I i
FROM TO DESCRIPTION i
Well Contractor Name ft. [L
4137-A ft. it. I I
NC Well Contractor Certification Number 15.OUTER CASINO(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETERTHICKNESS I MATERIAL
Clearwater Well Drilling Inc. 1 a- B4- ft ls). 't- I NO
-
Company Name 16.INNER CASING OR TUBING(geothermal d¢sed-loop)
(� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: 0� OO J 1 Ili ft ft. In. I
List all applicable well construction permits(i.e.County,State.Variance.etc)
ft. R. In, I '
3.Well Use(check well use): 17 SCREEN I
Water Supply Well: FROM To DIAMETER SLOT SIZE. THICKNESS MATERIAL
['Agricultural ft. it. in.
g ❑MunicipallPublicI
['Geothermal(Heating/Cooling Supply) Vitesidential Water Supply(single) ft. ft. "' I
❑lndusbial/Commercial ['Residential Water Supply(shared) 18.GROUT I
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Mitigation , rta it. efiMA- fin(VI
Non Water Supply Well:
[Monitoring ❑Recovery B• ft' I
Injection Well: it. it. I
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(If applicable) I
Cl Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
['Aquifer Test ❑StonnwaterDrainage R. ft rt I
. ft.
['Experimental Technology ❑Subsidence Control
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary).
FROM TO DESCRIPTION/� � (color,b irdness.sail/rock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) \ R, e tt. ft• c��l�l ll) 41 (i.{ r-4.
4.Date Well(s)Completed:r) I: 5-D4 Well ID# 4 ft. 1 ko 1 B. r p�l v ie
5a.WeilLocation: JC)tt N,�k rose- 1��' "� �Z�l �,x I _
-\ rrnn Cry?, ASSOClCd--es \teD aasft T � .
ft. ft C ^f
,,.-
Facility/Owner1k Herron
/ ' nl�l�Facility IDti(if applicable) ft. R. e i'- 4.,r dam,t i� 4
5$ l- on 'v {6 7 l � R. ,� 3 P ft i A ilH 0 202-
P ical Address,City,and Zip 21.REMARKS t
«rYl n,;,-ir,;t..,n;2r;-�.s,;.24R61 i 1•e#
County Parcel Identification No.(PIN) Itii4r
Q13°43 -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certify ,o
(if well field,one tat/long is sufficient)
Sign., of Certified Well Contracto Date
6.Is(are)the well(s): ermanent or OTemporary By st; ing this form,1 hereby certify that the well(s)tins(were)constructed in accordance
wid ISA NCAC 02C.0100 or ISA NCAC 02C.0200 W 11 Construction Standards and that a
7.Is this a repair to an existing went ❑Yes or )3(No •py of this record has been provided to the Well owner,
if this is o repair,fill out know,well construction Information and explain the nature of the I
repair under#21 remarks section or on site 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 additiohal pages if necessary.
For multiple injection or non-water supply wells ONLY with tiresome construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: c(Q5 (it.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1fdrjjerent(example-3C200lY mid 20100'j constriction to the following:
10.Static water level below top of casing: 0 (ft) Division of Water Quality,'Lsc Information Processing Unit,
If water level is above casing.use 1
"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. LgQ 10 (in.) 24b.For Injection Wells: In addition to sendi ig the form to the address in 24a
� „ I above,also submit a copy of this form within' 30 days of completion of well
12.Well construction method: 0-1-ar� 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(gpm) Method of test:. R;01 24c.For Water SUPDIV&Injection Wells: In addition to sending the form to
the address(es) above, also submit orie copy or this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to th i county health department of the county
where constructed.
Form GW-1 North Carolina Depanent of Environment and Natural Resources—Division of Water Quality
m Revised Jan.2013