GW1--02273_Well Construction - GW1_20240409

For Internal Use ONLY:
This form Can be used for single or multiple wells
1.Well Contractor Information:
i
Josh Plemmons 14.WATER ZONES I •
FROM TO DESCRIPTION I
Well Contractor Name it. ft. I I
4137-A ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If op Heable)
FROM
Clearwater Well Drilling Inc. ft. TO fL DIAMETER THICKNESS MATERIAL
/ I 8F i ��� } I pyc
Company Name 16.INNER CASING OR TUBING'(geothermal cioied-loop)
00913
�� 1 t/N'�� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: J O R. ft. 1 in.
List all applicable well construction permits(Le.Como%State,Variance,etc.)
ft. .ft. in.
3.Well Use(check well use): 17.SCREEN
I •
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) '�QResidential Water Supply(single) ft. R. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) FROMl8.GROUT I
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation / ft. `� fL /,�vfvt�� !vI ,p
Non-Water Supply Well: d ee t out i uz/t:./
❑Monitoring ❑Recov eR' rt. ft.
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable) ►
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD -
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology °Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.D UNCLOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(whr,hardness,soil/rack type,grain size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Re tics) 1 ft• O ft. a/)a )LIB-f-y--
2 2-Z4 r7 ft. it. I
4.Date Well(s)Completed:J" Well ID#
5s.Well Location: Ja C arSi' X- `'"/I 3 f, - ' `"-' ce I
ca�Q�(P. cede r rt. ft. I
Facility/OwnerName FacilityID (ifapplirable)
ft. R.
P rcal address,City,and Zip r
Z1.RE \
neO rrtt, APtilu i 1014
County Parcel identification No.(PiN) ini`lsrir4::.'n4 PC^^.5.D.21,--.c7 i,t7,p.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: D',7,011.3
(if well field,one latllong is sufficient) 22.Certification: 7 (�
N W7:-........------ 3-2-Ztf Certified Vell Contractor Date
6.Is(are)the well(s): �Pertnanent or ❑Temporary this form.I hereby certh'that the well(s)wits(were)constructed in accordance
' with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Wcll 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 well owner.
If this is o repair.fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide a itional well site details or well
8.Number of wells constructed: construction details. You may also attach additio'al 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: 4 a (ft.) 24a. For All Wells: Submit this form within 0 days of completion of well
For multiple wells list all depths lfdfjerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (SO (It,) Division of Water Quality,Information Processing Unit,
If water level is above casing,use '+ 1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (U ISin.) 24b.For injection Wells: In addition to sendink the form to the address in 24a
(�,M above,also submit a copy of this form within 0 days of completion of well
t-y� (Jl-•{12.Well construction method: , V t construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) _
Division of Water Quality,Underground injection Control Program,
FOR WATER SUPPLY LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1 lei
24c.For Water Supply&infection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test the address(es) above, also submit one j copy off 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 OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

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