GW1-2023-01181_Well Construction - GW1_20230127

WELL'CONSTRUCTION RECORD For Internal Use ONLY:
form
m can be used for single or multiple wells
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I.Well Contractor Information:
14.WA?SRZO
Josh Plemmons PRaM TO DESCRiPTiON
Well Cont"an,Tlame
4137-A & ft
NC Well Contractor Certification Number 1*p OU1FER CA9ING r mtt eel welds O L1N6[R IFa 1 bk
FROM TO I MATERIAL
Clearwater Well Drilling Inc. a iL 1 '°• VG
Company Name 1 INNER GL9lT1G t1RR11BIli1t1' HM 4 116
[[�� ("'y[� PROM TO DIAMETER THICKNM MATERIAL
2.Well Construction Permit#: IJ0 y-l 0.
Listall applicable well construdlon permits(i.e.Counly.Stale Varlaam etc)
3.Well Use(check well use): IT
Water Supply Well: tim R. TO ir: In.mAM atorslzr icic B93 MATERIAL
❑Agricultural OMonicilmUPablic
❑Geothermal(Heating/Cooling Supply) A-idential Water Supply(single)
n. iG �❑Industrial/Commercial OResidential Water Supply(shared) 1
FROM To MATERIAL -EMWACEMRNrk1rMoD&dKOM
Oltrigation, R. ft t
Non-Water Supply Well: n. fL
❑Monitoring ❑Recovery
Injection Well: n• n•
OAquifer Reehatge L1Groundwater Remediation l.. YEL PACK ff AlManull
17Aquifi:r Storage and Recovery ❑Salinity Barrier !f. TO ir.
MATBMAL I EMriACEMBNTMETHOD
❑Aquifer Test ElStormwater Drainage
❑Experimental Technology ❑Subsidence Control RiLI.WG l ,
❑Geothermal(Closed Loop) 07 racer :FROM
TO I DESCRt6 rION(color.MrtteU s@HF sck typ h fftm ere
❑Geothermal (Heating/Cooling Retum) 130ther lain under#21 Remarks R' OL"3i 4- 0 -�
yy 7
4.Date Well(a)Completed. 1 -y Well ID# IL B
Ss.Well Location:
Facility/OwnerNsrne Facility lD#(ifopplicsble)
p. it.
IN 5+ �t�rclSUi 1
Physical Address,City,and Zip
_ 21.REMM G5 !�
Cod .��n::.w,..i .s •l.Is-.:'.- Zia
Pascal ldentifica6anNo.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient)
Sign ofCenified Well Contractor Date
6.is(are)the well(s):*Permanent or CiTemporary B signitrg ibis form..I her chv certify that die we)1(s)xar(were)ronsnricted in awordance
dA ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well ConsMncllon Standards and that a
7.Is this a repair to an existing well: ❑Ves or k6a cop},of this rend has been provided to the well orwrer.
if this h a repair.fill on,Imarvn well construction lil/ormwion and explain the nahar ofthe
repolr under#21 reworks section or an the back ofibisfmm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
tl.Number ofweRa constructed: construction details. You may also attach additional pages ifnecessary.
Far multiple injectian or non-rvaterstrpply wells ONLPwith thesame construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9 Total well depth below hind surface: C9015 (ft.) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For mutripte wells list alidepthsifdprew(mmple-3@wo-and2a@100) construction to the fallowing:
to-Static water level below top of easing: (M) Division of Water Quality,information Processing Unit,
Ifwater level b above casing,use ,+° 1617 Mail SeI vlee Center,Raleigh,NC 27699-1617
11.Borehole diameter: On.) 24b.For Infection Wells: in addition to sending the form to the addnm in 24a
m L� yy above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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) t Method of tat; 9-S 24c,For Water Sandy At Infection Wells: In addition to sending the form to
the addresses)above, also submit one copy of this form within 30 days of
fib.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Eavironmant and Natural Resources-Division of Water Quality Revised Jan.2013
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well Droler self-Great Cord"Co""
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owner:Aab +-(
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I hereby catIfY that the above
x+demced well v►W groaned as appearance In ao=dar<ae with
all Cows W Wdi xvles.
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welt thi&r:•1l75�1 V`Q� d� - - ova------
Certificate#:
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Grout
Cons mCdon:
CasWg Type: -----
. casing
Diameer;�--
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Drive Shoe:
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