GW1-2023-01143_Well Construction - GW1_20230126

i
WELL CONSTRUCTION RECORD r
r internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons 14.WATERZ01�
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4137-A fL ft.
NC Well Contractor Certification Number 15.OUTER CASiNG ttmld-aced wdb OR LINER If a bk
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. I R• Up fL 4I f)VI,
Company Name \ ,(,�( �,�) G//�► 16.INNER CASING OR TUBING real
2.Well Construction Permit#: ) i�t�� �J t FROM ft
TO It. DIAMETER in. THICKNUS MATERIAL
List all applicable will construction permits(i.e.rCounty.Stale.Yariannce.etc.) fL ft. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLoTS1Z6 THICKNM MATERIAL
R. fa.
❑Agricultural ❑MunicipeUPublic R.
❑Geothermal(Heating/Cooling Supply) Residentist Water Supply(single) R' R la
❑Itldustrial(Comrnercial ,❑Residential Water Supply(shared) 18 GROUT
FROM TO MATERIAL EMPLACEMENT MW2D e AMOUNT
IlIrrization , R. 2D R. - 01
Non-Water Supply Well: ft R.
❑Monitoring ❑Recovery
injection Well: R. II.
❑Aquifer Recharge -OGroundwater Retllediation 19.SANDAMLAVEL PACK
FROM TO
R. EMri.A
❑Aquifer Storage"Recovery ❑Salinity Barrier MATERIAL CEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
R.
❑Experimental Technology El Subsidence Control DRILi.Q�G LOG WWII Additional siltrottl[
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION calar a sstllrock ate
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) tL
l 'L .
4.Date Well(s)Completed: 407 O e111D# ,v,0 R
R zR t
a.Well Location: 11 R
Fact ity Name Facility (if applicable) R.
fW IL
P ical Address,City, ip Z '3 21.PJLNL4 M
Y _
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degreestut autestseconda or decimal degrees: 22.0 lion:
(if well field,one lottlong is sufficient)
OEM' �o� 3�� �a°QaLo301%w - Z
Sig f Certified Well Contactor Date
6.is(are)the webs): Permanent or ❑Temporary �'sign this fwm.1 herehv cer*that the wells)was(were)constructed in accordance
with 1 NCAC 02C.0100 a 15A NCAC 01C'.0200 Well Consrrtwilon Standards and that a
7.Is this a repair to an existing well: ❑Yes or KNa copy this record has been provided to the writ owrner.
1(this is a repair,fill out known well construction information and explain the nanoe of the
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or nnn-water supply w/Ir ONLY with the ware rnasrrr cdon, ,on can
submit one form. � 1 SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: `J©` 1 (R) 24a. For AN Wells: Submit this fom: within 30 days of completion of well
For multiple melts list all depths iJdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,information Processing Unit,
tfwater level is above casing,use"+" II 1617 Mail Service Center,Raleigh,NC 176"-1617
11.Borehole diameter: 1 1 (in.) 24b.For Iniection Wells. In addition to sending the form to the address in 24a
i U above, also submit a copy of this forth within 30 days of completion of well
12.Well construction method: i t I Y,Y l�1 construction to the following:
(i.e.auger,mory,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) Method of test: 24c.For Water Supply&Infection 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 Wata Quality Revised Jan.2013