GW1--03186_Well Construction - GW1_20240524

---- ror internal Use ONLY: I
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. It
4137-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licabk)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. R. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
j, +I- D/0 07 f e- FROM TO DIAMETER THICKNESS MATERIAL2.Well Construction Permit#: hJ // It. in.
List all applicable well construction permits(i.e.County,State.Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
H. H. in.
❑Agricultural ❑Municipal/Public
,ieothermal(Heating/Cooling Supply) Supply(single)
ft' ft• in.
(Hearin Coolin Su I ❑Rtxidential Water Su 1
Olndustrial/Commercial ❑Residential Water Supply(shared) 1 GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft.
Non-Water Supply Well:
ft. ft.
°Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
❑Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I. 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 DESCRIPTION(color,bantam,solVrsek type,grain she,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#2!Remarks)- 0 ft- a75Th. ae0- ,f�i--n.}J �fr six.
ft. ft 424 It spa ✓4.Date Well(s)Completed: 7- i /� Well 1D# 11 ft.
5a.Well Location: Eric <To m /�fecia,n)J - ft.
liZr lc., Nwirlaie ) p rt. s-p ft. cro- -tyw_i 12&f-
Facility/Owner Name Facility ID#(if applicable R. ft.
�92 O row �4/JLcDn Ed All er �1 - , -^" 1
Physicalca Address,Cityy,and Zip
%e 1de tsvn 9/ 21.REMARKS
�D -•�� - 710�� MAY iZ/ 20'1
County Parcel Identification No.(PiN)
1.-:
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifreati r C +Cs'�J4
(if well field,one[at/long is sufficient)
p t -7 j� �(
;-1,"95.5) N 0 a 5q • 35. 3— W I 4-`7 'aCe
Signet fCertified eliContractor Date
6.Is(are)the Well(S):, Permanent or °Temporary By si rag this form,I hereby certify that the nell(s)arcs(acre)constructed in accordance
with ISA NCAC 02C_0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: °Yes or , No copy alibis 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#21 remarks section or on the back of this form. S-CI„ 23.Site diagram or additional well details:
,99 r 7' You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: -- asp ) construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells LIMY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (It.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
Ill water level 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 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 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