GW1--04052_Well Construction - GW1_20230622

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Josh
14.WATER ZONES I I
Plemmons FROM TO DESCRIPTION I
Well Contractor Name ' ft ft.
4137-A ft- IL
NC Well Contractor Certification Number I5.OUTER CASING(formulti-cased wells)OR LINER(if ap limbic)
FROM TO DIAMETER, THICKNESS MATERIAL
Clearwater Well Drilling inc. / It. /3 1L (�/Y'ia' I PV
Company Name D�� I �+ 16.INNER CASING OR TUBING(geothermal closed-loop)
J FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: R. ft. in.
List all applicable well construction permits(i.e.Counry.State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN } -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
R. ft. In.
OAgricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) ft. ft. in.
❑lndustria1lCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTEMPLACEMENTM/ETHOD&AMOUNT
(]Irrigation / ft. !7f(1 ft. ✓n�`-r r'u!t /�L1TM
Non-Water Supply Well: R. ft
❑Monitoring ❑Recovery
Injection Well: R. IL I
❑Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(Ifanpliceble) I
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R. R. I
❑Aquifer Test ❑StormwaterDtainage R. . It.
❑Experimetnal Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if nocessery)
lJGeothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color, nese,salrock type.grain shoe,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) / ft. I j R. Tar
� .fl.
. . lc3z)Ft. 76S ft. � 14.Date Wells)Completed: ' Well ID# R. ,�l�t5a.Well Location: fL R �/
DLu l l�" Woods LC. ft. fL �1!%��
Facility/OwnerName Facility IDA(if applicable) R, ft. ,�
ravel c� �a YV eu NG ft. rt. ( .
P ical Address,City.and Zi f 2I:REMARKS ! •
�,�,OM196 i JLry 2 202.3
County Parcel Identification No.(PIN) 1*i�",.41`v1 Pr-.,..
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifica, 7 DV 30G
(if well field,one latllong is sufficient) e
35'�-�'53. Ng <5�� SV W
-
,( Siva Licontmetor _ Date
6.Is(are)the well(s): Permanent or OTemporary By si 1 ng this form.1 hereby certify that the welf(s)was(sere)constructed in accordance
/ ` with SA NCAC 02C.0100 or ISA NCAC 02C.0200 Fell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l4o copy of this record has been provided to the'mil owner.
If this is a repair,fill out known well construction Information anf hplain the nature of the
repair under#11 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 providejadditionai well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you con
submit one form_ SUBMITTAL INSTUCTIONS
-7
9.Total well depth below land surface: f (/' (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Ifdiferent(example-301200'and 2@I00') construction to the following:
10.Static water level below top of casing: (ft,) Division of Water Quality,Inforn)ation Processing Unit,
If stater level is above casing,use"+"I/p 1617 Mail Service Center,Ral igh,NC 27699-1617
11.Borehole diameter: (.0 ( O (in.) 24b.For luiection 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: rb construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WE WE 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 count health department of the county
where constructed. I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan_2013

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