GW1--04109_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For internal Ilk.ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Josh Plemmons 21.WATER ZONES
FROM TO DESCRIPTION •
Well Contractor Name n, ft.
4137-A _ 'ft. ft.
NC Well Contractor Certification Number 1 S.OUTER CASING(for mul4i-caeed.welt.l OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft, ft. In.—
Company Name i6,INNER CASING OR TUBING(geothermal closed400p)
2.Well Construction Permit#: \ (" r^,' :FROM
TO DIAMETER THICKNESS MATERIAL
a- Ut w�� R. it, in.'
List all applicable well construction permits(i.e.County.State.Variance,etc.) --
ft. ft. in,
3.Weil Use(check well use): 17.SCREEN
Water Supply Well: PROM TO t DIAMETER SLOT SUE THICKNESS MATERIAL
R. ' ft. tL
❑Agricultural ❑Mtmicipal/Public _
_
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. iL ' — 1
•
O)ndustrial/Commereial ❑Residential Water Supply(shared) 1®'GROUT
SRAM TO , MATERIAL ' EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft.
Nos-Water Supply Well: --
ft. n.
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19. . DIGRAYELPACK - a _
FROM IIIMIIMIIIIME MATER AL EMPLACEMENT METHOD
°Aquifer Storage and Recovery ❑Salinity Barrier ft
' 1111111
❑Aquifer Test ❑Stonnwater Drainage --
ft. ft,
DExperimental Technology OSubsidence Control 21.DRILLING LOG(attach nidMianal sheets if Ileeasnry)
❑Geothermal(Closed Loop) °Tracer PROM TO DESCRIPTION feeler,Mdwp,.a Emit type,stein she,ac.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) C) a• ' 0`1- ()}
1-1-a`� ft. rt. U* + L Y1& !a
4.Date Well(s)Completed: WeII 1D# ft ft.—
Ss.Well Location: _. ft. ft.
\\ hY \C19e:'(l✓( __ ft, ft. .
Facility/Owner Name Facility iDN(if applicable) --
n. n.
Physical Address,City,and Zip \- ci ��-cpovi`ki aa_REMARKS 'L. 12 29t4 e_PoessonO Gnutty Parcel identification No.(PIN) *•-rw`-,',A.f
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 (,er. �on: ....r
(if well field,one fat/long is au tent) /
S. of Certified Well Contractor Date
6.Is(are)the well(s): 1iermanent or ❑Temporary s signing this form, I hereby cer that the well(s)alas
/ \ g )tg fo qfy (lucre)constructed in accordance
�' with I SA&CAC 02C.0100.Jr I SA&CAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yea or yprto copy of'this record hat been provided to the well owner.
If this is a)epatr..n11 ma known well comb-nation Information and plain the nature al the
repair under 82I 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 ityectlon or not)-w+Ner supply wells ONLY with the sane atpetlrrdfm0.yen)can
submit one fnnn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface; (fL) 24a. For All Wolfe: Submit this forrr within 30 days of completion of well
Far multiple wells list all(lambs ifdferent(eventide-3(a).200'and 2Q1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
Jfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (In,) 24b. For Inlection 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.yor Water SuDDIv&Infection Wells: ip addition to sending the form to
the address(ea) 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 OW-1 North Carolina Department of Envimnment and Natural Resource%-Division of Water Quality Revised Jan.2013