GW1--04943_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD
This form can he used for single or multiple wells For internal Use ONLY:
I.Well Contractor information:
Josh Plemmons 14.WATER ZONES
'.--FROM TO DESCRIPTION
Welt Contractor Name ft. n,
4137-A _ n. ft.NC Well Contractor Certification Number IS.OUTER CASING(for maid-cased wens)OR LINER(if ap lealile)
Clearwater Well Drilling Inc. FROM ft.
TO it DIAMETER in. THICKNESS MATERIAL
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
ZC_, 7 3 , 2�' 0 n _ ROi1 TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: L ' ��' I. Al'' ft. It in.
lid all applicable well construction permits(i.e.County,State,Variance,etc.) —
n. ft. i n.
3.Well Use(check well use):
17,SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE - THICKNESS MATERIAL i
❑Agricultural ❑Municipal/Public n• it, in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial 1R.GROUT
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Residential Water Supply(shared)
❑Irrigation
FROM
Non-Water Supply Well: / IL ,q7; iL /are 7f Of 9 -/
❑Monitoring DRecove ft. ft. l 1KC,� / / {�
ry
Injection Well: rt. ft.
—
❑Aquifer Recharge [}Groundwater Remediation 19.SAND/GRAVEL PACK Of appllcatls1FROM
-
❑Aquifer Storage and Recovery ❑Salinity Barrier Tn MATERIAL EMPLACEMENT METHOD
fL n.
❑Aquifer Test OStormwater Drainage —
ft•❑Experimental Technologyft.❑Subsidence Control
2®.DRILLING LOG(attach addldonal sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer
FROM To DESCRIPTION(cobr,hardness,soil/rack type,grain sra,etc.)
❑Geothermal(Heating/Cooling
Return) JJ l❑'Other(explain under#21 Remarks) / it" & 3 11" , S�)' 71-C-,�`/
4.Date Well(s)Completed: 1 -W"G Neil ID# j n. 4l � it. /j1i,'If /J�1i
5a.Well Location: (��s 6„�/ ft. t/JJfALG��1'LpT L
n a JrUJJ Facility/Owner Name Lot-(3 I Facility(Du(if applicable)
n. n. T••
C►(. n\\ 11Gt.{ R AS) Min . l .i are ft. n. r� 10Z4
Physical Address,City,and Zip !!
ro.` k 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat./long is sufficient) 22.Ce on:
_ ° 148 135,1 N i>r Ill C+ =l W l.—__ !�_ — U
Sig of Certified Well Contractor Date
6.is(are)the well(s): Permanent or ❑Temporary
B .signing this form, I hereby certify that the well(s)was(were)constructed in accordance
,With 15A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Jo copy of this record has been provided to the well owner.
If Ibis is a repair,fill out known well construction information and explain the nature of the
repair wider#21 remarks section nr 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 welt
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same� construction,you can
St/1HW!nne,form. �� SUBMITTAL INSTUCfIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3@200'and 441 00') construction to the following:
7an
10.Static water level below top of casing: /Cam) (ft.) Division of Water Quality..information Processing Unit,
If water level is above casing,rise"+•• ( 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Cv /''' (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
�y
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: rV/ant 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) /z Method of test: gig
24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit ore copy of this form within 30 days of
completion of well construction to the county health department of the county
13b,Disinfection type: Amount:
where constructed.
Form GAT-I North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised Jan.2013

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