GW1--04101_Well Construction - GW1_20240712

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES
Josh Plemmons FROM TO DESCRIPTION
Well Contractor Name ft. H.
4137-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap liveable)
_FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft. L f ft. Gj ii in. PVC,
Company Name �J / 16.INNER CASING OR TUBING(geothermal closed-loop) J`
2.Well Construction Permit tl: _0 ^ p(C :22.,3 �pi{i f FROM ft _TO ft DIAMETER in. THICKNESS MATERIAL
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 it ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ,esidential Water Supply(single) ft. ft. in. -
❑lndustrial/Commercial El Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL�} EMPLACEMENT METHOD- &AMOUNT
❑irrigation i ft. c�(O ft. �r_�rl Icy 1� iv/f/l
Non-Water Supply Well:
ft. it.
❑Monitoring ❑Recovery
injection Well: ft. H.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicably
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM • TO DESCRIPTION(color,hardness,sail/rock hoe,grain size,etc.)
❑Geothermal(Heating/Cooling/�Return) l❑Other(explain under#21 Remarks) / ft- V ft• ,.c a B't,/ / _,//� /-
it
4.Date Well(s)Completed:((/ "3-�CJ Well ID# ��(` R )7�ft �t�ctl( �f�/>A�`
r 76 r7 7 7 �� CX
5a.Well Location: ft. H. 1
D/7'l(,t S /aGi}o/3 ft. rt.
Facility/Owner Name (Di I' Facility ID#(if applicable)
ft. ft.
it/ 11ioccf Sort-e I Ln-. ft. ft. t- JEa-
Physical Address,City,and Zip 21.REMARKS
enCiercDn IOL 1 2 2024
County Parcel Identification No.(PIN)
lr.M.ar.4 1 4r.-e• urot
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.CertiTi on (:b +til
(if well field,one lut/long is sufficient)
IIP. 1✓', 5 N Y '70 ' Y I,9 c(- W 67 - (U a y
Sig ure of Certified Well Contractor Date
r
6.Is(are)the well(s): (rItermanent or ❑Temporary .signing this form.I hereby cerdh'that the uiell(s)was(mere)constructed in accordance
,with ISA NCAC 02C.0/00 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 10 copy of this record has been provided to the sell owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the hack 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 additional pages if necessary.
Far multiple injection or non-Crater supply wells ONLY with the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3Lt-.. (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(crumple-3C,200'and 20_100') construction to the following:
10.Static water level below top of casing (QC (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
II.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: tor 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) 3 Method of test: it1 C,i 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
completion of well constntction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013

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