GW1-2021-04572_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD For Imcnial Use ONLY:
This form can be used for single or nultiple wells
1.Well Contractor Information:
Josh Plemmons 14.WATBRZONO s
FROM TO DFSCRWnON
Well Contractor Name ft ft. 4
4137 A ft ft p
NC Well Contractor CertificationNumber 1S.OUTERCASING formutd-eased veh ORLINER rfa m61e
AfATQtG1L
Clearwater Well Drilling, Inc. Hot Springs, NC 28743 FROM I TO DIAMETER THICKft- 1,00 fL m
Company Name 16. ERCASING"ORTUBIN thetmalclesed=loo )_. -
FROM TO DIAMETER THICKNESS MATEBtAL
Z.Well Construction Permit#: l R in.
List all applicable well permits(i.e.C—%State,4arl- Injection,etc.) _
AL ft.
in.
3.Well Use(check well use): .SCREEN
Water Supply Well: FROM TO DtA ILTER.. SL01'SIZE I THICKNESS ._MATEtuAL :-
R
gricuittmal ❑MunicipaUPublic R in.
❑Geothermal(Heating(Cooting Supply) ❑Residential Water Supply(single) ELtO
Olndustrial/Commercial ❑Residential Water Supply(shared) 11-GROUT< ;
FROM TO MATERIAL EhIPI.A .METHOD&AMOUNr
❑Irrl t10m � �
Non-Water Supply Well: R ed
ft
❑Monitoring ❑Rewv�t
Injection Well: R It.
❑Aquifer Recharge ❑GroundwaterRemediation 19=SANDlGRAVSLPACK ifa ltcable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACElI EUrfitMOD
R ft
❑Aquifer Test ❑StormwaterDrainage ft R
OF-xperimentat Technology ❑Subsidence Control
ZO:DRILLING LOG attach additionatsheetsif necessary
❑Geothermal(Closed Loop) ❑Tracer EFROMTO DESCRiITION calmhaidaeuautreck shc,etc.❑Geothermal(Heating/CoolingRedun) ❑Other(explainunder#21 Remarks) © & %Y44-
fZ4.Date Well(s)Completed: Well ID# '�. ,�1So.Well Location• I w
ft ft
Facility/Owner Name Facility IM(ifapplieable) R %
A
Physical Address,city.and Zip a1:REMARKS _
County Parcel Identification No.(PIN)
Sb:Latitude and Longitude in degreestminatestseconds or decimal degrees: 22.Certification: T1" �NR$eCt'0
(ifweU field,one lat/long is sufficient)
35a E'�zo N— a: -314 X
S' tore of CertiS�Wen Cofactor Date
6.Is(are)the weU(s)- ermanest or ❑Temporary
By sig/ting this form,I hereby cerr fy what the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC'03C.0200 Wdl Construction Standards and dint a
7.Is this a repair to an existing well: ❑Yes or
copy ofthis record has been provided to the well owner
/f this is a repair,fill our known trell construction information nd explain the nature ofthe
repair under�121 remarks section or on the back of thisform 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
&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
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft:) 24a. For All Wells: Submit this form within 30 days of completion of well
For—triple wells list aB depths ifdiffereni(ammple-3(g00'aml2®100') construction to the following
10.Static water level below top of casing: (ft Division of Water Resources,Information Processing Unit,
Ijuarer level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (ia) 24b.For Infection Wells ONLY: 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
(Le.auger rotary.cable,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: r 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ao Method of test: �? 24c.For Water Supply&Infection Wells:
Also submit one copy of this form 1within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Nadaal Resources—Division of Water Resources Revised August 2013
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