GW1--03693_Well Construction - GW1_20240618

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
14.WATER ZONES
Josh Plemmons FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4137-A it. R.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-eased*IA OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL l
Clearwater Well Drilling Inc. i a. L c.3 R- in. St��. 1
Company Name J`� 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit a: O{l/�c 3 -�OI / FROM
TOft. DIAMETER In THICKNESS MATERIAL
�jpl1�
List all applicable well construction permits(Le.Coxny.State.Variance,etc.) R. ft. In. -
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. R. In. -
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. In.
C)lndustriallCommercial []Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation I- (.f Li R. [� KMer)t- m i ed
Non-Water Supply Well:
ft. R.
❑Monitoring ❑Recovery ,
Injection Well: ft. ft.
_-
❑Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if appllcabI
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. R.
❑Experimental Technology ['Subsidence Control 20.DRILLING LOG(attach additional Aegis If aecessary)
[JGeothermal(Closed Loop) OTracer FROM I TO DESCRIPTION(color,►ardoess,loll/rock type,Fota are,etc.)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) i R. I) ft. am L(( 51�A * `"-�
r ^ + W-
4.Date Well(s)Completed: Well ID# {i R. f
R. IL
5a.Well Location: R. ft.
,i P c 're i Mel SOn R. R.
Facility/Owner Na Facility IDS(if applicable) ft. ft.
H-3 bimiciy (mod) R. .. - _ _ ✓E)
Physical Address,City,and Zip 21.REMARKS 1'$ 2024
County Parcel Identification No.(PIN) ‘rfi s.,.w"4''l Ud'd
1M rICt
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.C - a: 1•
(Swell field,one lot/long is sufficient)
=��' 4$ 'Ct< , 4 N c 4�-'5° ,tU w _ tom._— - 1I v� `f
Si of enified Well Contractor Date
6.Is(are)the well(s): Permanent or °Temporary By s' 7rg this form.I hereby certify that the nell(s)was(Here)constructed in accordance
nit I5A 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 `
9 Jo y ofthls record has been provided to the well owner.
((this is a repair,Jill out known tic!!construction Information a d explain the nature of the
repair under 021 remarks section or on the back of thts form. 23.Site diagram or additional Well details:
You may use the back of this page to provide additional well site details or well
B.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or Iron-water supply wells ONLY with the same construction,yin.can
submit one farm. SUBMITTAL INSTUCTIONS
r'i '' 24a. For All Wells: Submit this "arm within 30 days of completion of well
9.Total well depth below land surface: I (ft.) Y W
For multiple wells list all depths ifdierent(example-3®200'and 1@100') construction to the following:
10.Static water level below top of casing: (_C'C' (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: tj.) I ri (in.) 24b.For Iniecdon 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: I L C,\ \ 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: fin/ (�I 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) .- Ck)} ' Method of test: Q iq 24c.For Water Supply Se Ipiectioti 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 constriction 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