GW1--04118_Well Construction - GW1_20230623

WELL CONSTRUCTION RECORD Far Internal Use ONLY:
This Rum can be used for single or multiple wells
I.Well Contractor information:
Josh Plemmons 14.1VA'1'RRZON138 '
•
FnoM TO _ DESCRIPITONI I
Well Contractor Name ft. it. I
4137-A ft ft'
C� NC Well Connate/Certification Number WHIM 1NG true mnitEeatedvr SkOR LIN761t{ItaDpifrirbte)
FROM TO DIAMETER TNici ua9S MATERIAL
Clearwater Well Drilling Inc. B. ft. M. I
Company Name J %� /� �Q IS:INNIE t CASING ORTURINGIRROUNOnl III ilitijl) ,
2.Well Construction Permit#t i V I— v l"D F/ FROM TO DIAMETER TBIGIiiV&S9 MATERIAL
ft ft. In. I
List all applicable well constntcilon permits(i.e.Count',State.Variance.etc.) I
It. in.v ft.
3.Well Use(check well use): 17• I.
Water Supply Well: PROM TO DIAMETER SLOT SIZE 1 'THICKNESS MATERIAL
ft. It. in.
['Agricultural OMunicipal/Poblic
'qeothetmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft In.
❑Induslrial/Commetcial ❑Residential Water Supply(shared) .18.GROVY i
F1IOM TO MATERIAL• EMPLACEMENT METRODitAMOUNT
°irrigation it II. I
Non-Water Supply Well:
•
i]Monitoring °Reco rt. ft. _ I
Injection Well O. etc I
['Aquifer Recharge .❑Groundwater Remediation •19,1310DRAVZL PA Ofiill e) I
OAgniti r Storage and Recovery ❑Salinity Barrier FROM TO MAMMAL EMrLACEMENrMETHOD
❑ ifer Test
�N [StormwaterDrairmge n• II.
['Experimental Technology [Subsidence Control
['Geothermal(Closed Loop) [Tracer 20.DRILL*i oM iamb sldtatimtrfallnditlfat tt inVY .
FROM TO DESCRIPTION(color,Medina,sailhack :Tn*Nets.)
❑Geothermal(Heating/Cooling Return) [Other(explain under NI Remarks) 0 f. 3 ft., qeD ;► rMI .JJ 6. 4-god
B- it I`�-f
4.Date Wells)Completed: Well 111# D n (97 3- Q p sin / I Tad--
r 4-sand
Sa.Well Location:• gµnt�> ////1' n y ft. J lam, 't�1 I s A {/���J
S of t 1 1//1 t I✓erpo- () ft j () ft ah 1�n I ,.I'ri b7 'T 4 L"'*.t.
1��3 Name Facility
/'l�. l�L.t'- (J�l'GC ai®ie) R.v v R. � I � ��.�,•�...e bi fit! i'' °X
tt I JUN 9 = 2023
Phi Address,City,and Zip -
Yn C`/ �l �//,1� (X,`r 2 G�l ��J�] 9t x j� 21,KIRKS ,I ,[
County iJ 7. la Vf V/ U J/V o!v /W J- -NO lIpfofNrt.wr/en Prrr v?ye. ,j`U la
County / Y Parcel Identification No.(PIN) I LA�a�,' 3
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certif" on:
(if well field,one lat/long in sufficient)
�3S' M137. N gZ "v`�7 ifD �f, S W - W-Z 3
Sig :.s. ofCertified Well Contractor I Daze
6.i3(are)the well(s): Ilermanent or CITemporary By✓igning this Joan.1 herehy cart*that the wells)war(were)vomit: red in accordance
7.Is this arepair to an existingwell: [Yes or o ,,lh ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construct/on Standards and Thal a
copy of this record has been provided to the well ouwer.
Iflbxs Iv a repair.fill out brown well construction Information and explain the natt of the
repair under#21 remarkrsedlon or on the back ofthisfarm. 2 4,,. 23.Site diagram or additional well details:
t•.1. _ VW-Pt You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 2- F f• construction details. You may also attach additional pages if necessary.
Far multiple injection orlon-wetersrpply wells ONLY with the same co or.you can
submitonafornr. SiIBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: (at.) 24a. For An Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferen,(crmnple-3Q200'and 2Gd100') construction to the fallowing.
10.Static water level below top of casing. (ft.) Division of Water Quality,information Processing Unit
if water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: (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: construction to the fbifowing
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test 24c.for Water Snooty&Inteetlon Wens: In addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfeedon type: Amount: completion of well construction to the'county health department of the county
where constructed.
Forth OW-i North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013