GW1--04944_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I.Well Contractor information:
Josh Plemmons 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
fL R.
4137-A r f
NC Wel Contractor Celli()cation Number 1S.OUTER CASING(tor malt)-cased wellA9R LINER(if tap hue)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. •
Company Name 17 l 16.1NNER CASING OR TUBING(geothermal closed-loopl_
( I 7TO
2.Well Construction Permit#: �" " I L T I EOM DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.County,State,Variance,etc.) ft. R' in. —
3.Well Use(check well use): ft. ft. in. —
17,SCREEN
n Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural °Municipal/Public ft. ft. Ia. —
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) n ft. in, —
❑Industrial/Commercial ❑Residential Water Supply(shared) Ili'GROUT
❑trtiga[ion FROM , TO MATERIALE EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ; It. 7 ft. !`f2i/ ell f MI t C/
aG' l XC
iJMonitoring ❑Recovery ft. ft.
injection Well: ft. ft.
—
DAquifer Recharge ❑Groundwater Remediation It SAND/GRAVEL PACK Of appltcaldc)
❑Aquifer Storage and Recovery °Salinity Barrier FROM To MATERIAL_ EMPLACEMENT METHOD
°Aquifer Test ft. rt.
°Stormwater Drainage _
❑Experimental Technology ❑Subsidence Control It. ft.
❑Geothermal(Closed Loop) ❑Tracer 29.DRILLING LOG(attach additional sheets If aeeessary)
FROM TO DESCRIPTION(color,t ardaea,sallinck t�e.jrsna sot,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) / 0• 7v ri 11/1� r,/_�,/,r —
I J �7/,, c r[[f lr(,cif T
4.Date Wells)Completed: I"31 ' Well ION
! 0 ft-
fart• f J1 J J
5a.Well Location: (97t f� ,,97/ R' t
` oho Macera �77 oft. t 9YWZI/t'
Facility/Owner Name Facility 1D#(if applicable) R.
A 13 (21�k (�OC1 QJ , _ ft. ft.
��
j�,.
p ft. IL l 1,. D Physical Address,City,and Zip
1!„c Lacy'\ 21.REMARKS )L -o ��
■
County ' 1 Parcel Identification No.(PiN) am--
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 4
(if well field,one 1st/long is sufficient) 22.Certific lion:
4--i
i `,
6.Is(are)the well(s): Permanent or ❑Temporary Signa.,f of Certified W I Contractor Date
By.s• lag this form. i hereby certify that the well(s)was(were)constructed in occo,dance
7.is this a repair to an existing well: ❑Yes or o wi 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Weil Construction Standards and that a
y of this 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. 23.Site diagram or additional well details:
8.Number of wells constructed: You may use the back of this page to provide additional well site details or well
For multiple injection or non-water supply wells ONLY with the same mute:action construction details. You may also attach additional pages if necessary.
submit one form. " `ca
SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3a J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(([different(example-3l 200'and 2@I00') construction to the following:
10.Static water level below top of casing: t.o D (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use''11+•nn 1617 Mall Service Center,Raleigh,NC 27699-1617
lY
I I.Borehole diameter: tl (in,) 24b. For Iniectiou Wells: In addition to sending the form to the address in 24a
���tly r� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: I C construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) i 3 Method of test: ICC 24c,For Water Sootily&iniection 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

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