GW1-2023-01184_Well Construction - GW1_20230127

i
WELL CONSTRUCTION RECORD For lutenist Use ONLY:
This fmm can be used for single or multiple wells C 1.Well Contractor Information: L
Josh Plemmons It.WATBRZONE
FI[am TO 1010"iMON
WellConttacttlrName R• R'
4137-A ft. ft.
NC Well Conqueror Certification Npminr 1 OUI'INt CASING we li O L hat
PROM T ETER O DIAM TiaCRM9S MATERIAL
Clearwater Well Drilling Inc, fL LA I rt: t [(S3 'm L INC
Company Name 1' ROM *ASING ORTTMING Ai j III l owl lid-
PROM( TO DIAMETER THICKNESS MATMAL
2.Well Construction Permit#: tt, AL In.
List all applicable wen construction permits(i.e.County timle.Vartance,e1c.) ft rf. in.
3.Well Use(check well use): I? gp
Water Supply Well: FROM TO DIAMBTER BLOTSIZB THICKNESS MATERIAL
)kAriculoural- V'0-rM W e t I DMunicipal/Public n• >r: to
(�. (��l3eothetmel(Heating/Cooling Supply) residential Water Supply(single) Ilk.
❑industrial/Commereial ❑Residential Water Supply )1 shared I Gltot)T
FROM TO MATERIAL VAIMACEMRNTMMODkAMOUNT
❑rri tion I R .M l VQ
Non-Water Supply Well.-
[Monitoring ❑Recovery fr. tt
injection Well: n• n
❑Aquifer Recharge .06roundwater Remediation V SANKViiL PACKAfanailuffill
DAquif:r storage and Recovery OSolinity Barrier
FROM TO a M MAIMAL SNACEMENr hWMOD
D.
❑Aquifer Test 13Stormwater Drainage
Il. ft.
RExperimental Technology OSubsidence Control 211,DRILLWG 1LOG add] ii it
(]Geothermal(Closed Loop) []Tracer FROM TO DESCREM13N color,hanbuia,nflit«k 414 grainthe dc.
OGeothermal (Heating/Cooling Return) OOther(explain under#21 Remarks) t D' D• O '11C Y
4.Date Weil(s)Completed: Well ID# I IL ��
So. .
Location
tt. o. l-
Jim (2"Wc�)�O-n ft , % J
Facility/Owner Name J tY ID#(Facility (Ifa 6 )
cable
��� V 1 'i` IV R. It.
Physical Address,City,and Zip �- 1
S�1C.P_�1 21.RB1►lA1Rxs - -
lrn�.,rt,:�
C Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreesftninutes/secouds or decimal degrees: 22.Card don:
017well field,one Intliong is sufficient) 6
Sign oft ertified Well Contractor Date
6.is(are)the wcff(a):X\Permaneot or []Temporary
lly s IA$this form,i herehv certify that the>tmp(s)rvos(were)ronstrtreted in accordance
with!SA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Coma rtctlon Standards and that a
7.Is this a repair to an existing well: Dyes or wo cop},ofthls recard has been provided to the ivell ouwer.
(fthls Is o repair,fill our known well construction i*rmarion and Aplain the nanrre afthe
repair under#21 remarks section or on the hack ofthlsfarm. 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 net ry.
Fnr multiple McCrion or non-water supply wils ONLP with the same construction,pal can
suhmitoneform. SUBMITTAL INSTUCTiONS
9 Toni well depth below Ind surface: 445 (ft.) 24a. For Ail Wells: Submit this form within 30 days of completion of well
Far'muhipleMth list all depths fd111erenJP=vple-3@200-aAd2@100) construction to the following.
10.Strtic water level below top of easing: (g;) Division of Water Quality,information Processing Unit,
Ifwater level it above casim,we"+"[ 1617 Mall Service Center,Raleigh,NC 27699-1617
1 L Borehole diameter. La (in.) 24b.For Infection 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: t,C,R construction to the following:
(i.e,auger,rotary,cable,direct push,eta)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Maii Service Center,Raleigh,NC 27699-1636
139,Yield(gpm) Method of test l 24e For Water Supply&latetdion M11s: In addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
131L Disinfection type: Amount: completion of well construction to the county health depnitment of the county
where constructed.
Form OW-1 North Carolina Departmentof Environment and Natuml.Resourees-Division of WalcrQeality Revised Jan,2013