GW1-2023-01141_Well Construction - GW1_20230126

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons FO WATER T'O DESCRIPTION
Well Contractor Name Tt. 1L
4137-A ft.
fL
NC Well Contractor Certification Number t •O CASING ~� OR LINER Ba hie
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. rt ti 'j In.
Company Name 16.INNBR CASING OR TUBQIG thlra- elaCKK
0��� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: c,W Z7—' ! IL IL tn.
List all applicable well construction permits(i.e.County.Stata.Variance,etc.) & fl. try
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZH THICKNESS MATERIAL
fl. ft.
❑Agricultural ❑MunicipaVPublic
ft. ft. Is.
❑Geothermal(HeatinglCooling Supply) okesidential Water Supply(single)
❑IndustrialiCommercial ❑Residential Water Supply(shared) IS.GROUT
MROMTO MATERIAL EMPIACEMENT METHOD&AMOUNT
❑lrri ation Non-Water Supply Well:❑Monitoring ❑Recoveryinjection Well: IL
❑Aquifer Recharge ❑Groundwater Remediation RAVRL PAt^K
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL fL
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 20 DRUAJNG LOG I a1ldNioad Ants Hlrneena
❑Geothermal(Closed Loop) ❑Tracer FROM 1iD "$CRWFION ic.W,W »ivr"k nta abr ele
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) RREMMIMM
ft
4.Date Wells)Completd ell I5a.Well location: 4126 STcwv acidity/Owner Nama Facility 1D#(ifapplicable)+{///gJ1hys'icaaltyAdddreess,CLity,a`nnd Zip �1G
' RA.f F 1 7 x l of cl
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ICion:
(ifwzzell field,one lat/long is suffficiern)
0--r�` �IYJIYN W —Zb -
�,[Lrtified Well Contractor Date
6.Is(are)the weU(s): L�'ermanent or ❑Temporary form.I herehv colijy that the,well(s)%w(were)construc►ed ix accordance
/\ 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this it repair to sun existing well: ❑Yes or XNe copy of this record has been provided to the well owner.
(fihis is a repair,fill out known well construction information and explain the novae ofthe
repair under 421 remarks section or on the back of this farm. 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 mih the same construction,)vat can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: qDS (ft.) 24a. For AB Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdii ferent(example-3Cr�200''afnndd 2@100') construction to the following:
10.Static water level below top of casing: U v (ft-) Division of Water Quality,Information Processing Unit,
/f wetter level is above casing,use"+"1 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ' U (in.) 24b.For Iniectlou 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: f t, �f 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
t
13a.Yield(gpm) Method of best: 24c-For Water SUDDIV&lniectlon Wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.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]an.2013
I