GW1-2023-01111_Well Construction - GW1_20230126

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can he used.for-single or.multiple wells------ _ _.._--------.------ --------- - _..--- - -- - - - - -
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1.Well Contractor information:
i4.WATER ZONES
Josh Plemmons FROM TO DESCRIPTION i
WellCantmctorName ft ft
4137 A fL
NC Well Contractor Certification Number 15.OUTER CASING or molt-cared wella ORLiNER A Qeable
FROM TO DIAMETER ! THICKNESS MATERIAL
Clearwater Well Drilling Inc. f - f. UP5D (L 1 '°'
Company Name /ry Ia.INNER CA91NG ORTUBING t11Ct Hit eleled•lo6
a� ��� J FROM TO RL4MET6R iHICKN&SS MATERIAL
2.Well Construction Permit#: R. rt
Listoll applicable well construction permits(1.e.Count)t Stag Variance.etc.) in.
3.Well Use(check well use): 17.SL'RL+FdH
FROM To DIAMETER 9LOTSIZti THICKNESS MATERAAL
Water Supply Well: ft. fh in.
❑Agricultural ❑Mur»cigaUPublic is
[]Geothermal(Heating/Cooling Supply) [residential Water Supply(single) ft R.
❑Industrial/Commercial AResidential Water Supply(shared) 18 GROUT
FROM TO MATERIAL ,y EMPLACEh1ENTMETAOD&AMOUNT
01rd tion R. I
Non-Water Supply Well: ft. R.
❑Monitoring ❑Recovery
R. R.
injection Weil:
❑Aquifer Recharge OGroundwater Remediation MD,
RAo L PACK MATERrATile gMPLACEMENf METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier it
❑Aquifer Test ❑Stormwater Drainage R.
❑Experimental Technology ❑Subsidence Control NG LOG Atmeh ittiditlond lbeele tf neeesaa
❑Geothermal(Closed Loop) OTracer TO DESCRRP770N color 6ttrda solUeock aim,etc
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❑Geothermal eati oling Return) ❑Other(explain under#21 Remarks) 1 R
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4.Date Well(s)Completed: Well ID# ft %R.
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5a.Well Location: R. R.
/Facility/ er Name Fa'ity,iD#(f applicable) ft. t r.-,
77 If pJ ,s 1, I n
Physics Address,City;and Zip 21.REMARKS
0/1 �U61JAN " LUO
County parcel Identification No.(PIN)
5b.Latitude and Longitude in nitinutes/seconds or decimal degrees:
g � � VsigoofC—cnified
ation:
(if well field,one lattiong is sufficient) t
0-55
Weil Contractor Date
6.is(are)thewcR(s): Permanent or ElTemporary By Signing this form,I herebv certify that the%wills)was(were)constructed m accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a -
7.Is this a repair to an existing well: OYes or V. copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill oil known well construction information an✓d` lain the nature ofthe
repair under 02)remarks section or on the back 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 accessary.
For multiple injection or non-water supply wells ONL F with the same construction you can
submit oneform. f ( SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1 �1 (ft.) 24a. For All Wells: Submit this ifoim within 30 days of completion of well
For multiple wells list all depths ifrOfjerml(example-3@200'and 2Cja 100) construction to the following: I,
10.Static water level below top of casing: (ft-) Division of Water Quality;Information Processing Unit,
Outer lavel is above casing,use"+" ` 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: (in.) 24b.For iniection 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 j
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n 163E Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: �`t✓ 24c.For Water Supply&Injection 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. I
Form dW-1 North Carolina DepartmentofEnvironment and Natural Resources-Division of Watcr QIi ity Revised Jan.2013
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