GW1--05782_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD
This form can he used for single or multiple wells For internal Use ONLY:
1.Well Contractor information:
Josh Plemmons 14.WATER ZONES
FROM I TO DESCRIPTION
Well Contractor Name ft t1.
4137-A ft• ft
NC Well Contractor Certification Number IS.OUTER CASING(for main-cased atilt OR LINER Of all yeable)
Clearwater Weil Drilling Inc. FROM
OM ft 1 I ft' ot�M'T la. THICKNESS MATERIAL
PVC
Company Name (6.INNER CASING OR TUBING(geothermal dosed-loop)
dD 69V 5 -Q ls�_d yJ.) FROM 70 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: `l7 ft, in.
List all applicable well construction permits(i.e.County.State,Variance.etc.)
ft. ft. is
3.Well Use(check well use):
17.SCREEN
Water Supply Well: 'ROM TO DIAMETER ' SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public n ft is
OGeothermal(Heating/Cooling Supply) kfitcsidential Water Supply(single) ft ft• t^
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation n. r�C� h
Non-Water Supply Well: ' ,_ 1 .eQ it 1 �1\ (6
❑Monitoring ❑Recovery ft. ft.
injection Well: rt. ft.
DAquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK Of applicablg
°Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test m ft' ft
DStorwater Drainage —
❑Experimental Technolo ft• ft,
gy ❑Subsidence Control
OGeothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional aka,if aeeeuary)
FROM TO DESCRIPTION Kolar,kerdaw,so'Vrock type,gnats size,etc.)
DGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) i ft' 1-7 ft �(]J .n cL
- f 4 cif t��
4.Date Well(s)Completed: Well ID# ,-7 R. Q, ft• rn �� � ' ^ _
Si.Well Location: �}`^R a1-) • 1 �-'1
h1/'Ui/1.m 7, Sy, er,%r. �» a ,305 a �j • +e
Facility/Owner Name Facility iD#(if applicable) i
ft-
Physical Address,city,and Zip o >t F 2 0 2024
Jac kso r �' REMARKS
-ram-4'J?,t
^ Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certi
' 33' Ute r161 N s'i ' 15' 36i' . y lG w S—q —(9 V
Si re of Certified Well Contractor Date
6.Is(are)the well(s): )(Permanent or ❑Temporary
' By,igning this form,1 hereby eeltil that the w 21:Wwas(were)constructed in accordance
`/ th/SA NCAC 02C.0/01)or 1 SA NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well; ❑Yes or C}(IVo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information a explain the nature of-the
repair under#2!remarks section or on the bock of this fonn. 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.
For multiple injection or non-water supply wells ONLY with the same eenstrnetinn,you can
srtbmitnnefonn. SUBMITTAL INSTUCPIONS
9.Total well depth below land surfs.: (ft.) 24a. For All Wens: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and�2(a`)100') construction to the following:
V
10.Static water level below top of casing: CO (fL) Division of Water Quality,Information Processing Unit,
If water level is above casing.use-r i�+.• 1617 Mail Service Center,Raleigh,NC 27699-1617
l
11.Borehole diameter: . t/ % (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
(�LJ _ above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: i � 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) e.D a' Method of test: ( 1 24c,For Water Supply&injection V'LeIIs: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 Ian.2013