GW1--04861_Well Construction - GW1_20230728

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons 14.WATERZONES I : '
FROM TO DESCRIPTION] I
Well Contractor Name R. R. 1 -
4137-A ft. ft.
NC Well Contractor Certification Number - IS.OUTER CASING(for-multi-ccased wells)OR LINER(if ap lieable)
FROM TO • DIAMETER THICKNESS I MATERIAL
Clearwater Well Drilling Inc. 1 R. �(r5 iL in. I S} j
Company Name �f���} 16.INNER CASING OR TUBING(geothermal doled-loop)
o[t�Y�(3 ���� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well construction permits(i.e County.State.Variance.etc)
ft. It. In.
3.Well Use(check well use): 17.SCREEN i
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL '
DAgricultural °Municipal/Public R. R in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) it. In.
flndusttial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL EMPLACEMENTPL METHOD&AMOUNT
❑Irrigation l R• 20 R- ceinant (tc lad
Non-Water Supply Well: R,
❑Monitoring ❑Recovery
Injection Well: R. It I
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If appileabie)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Stomp and Recovery ❑Salinity Barrier R, R, I
❑Aquifer Test ❑StormwaterDrainage ii. R I
❑Experimental Technology ❑Subsidence Control 20.DRiLLBVG LOG(attach additional sheets If a aassary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO • DESCRIPTION(color.hirdacss,soil/rock Noe.Vela eke.etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I ft• 55 1ft• Sa C't :14-)-
4.Date Wells)Completed: Well ID# t R: 1_DO`� • ll,'i�4
R. R. Ta
_
5a.Well Location: ft. R. Z b .1- e �,
\1OrKe Pharr ft. ft. . w_
Fa lity/OwnerName Facility lull(if applicable) ft. ft i JUL Sd 6Z0Z3
`3COZ 'Oohs Cre6Y, a" a • ft. R. Irtfhrinutitm P:%:.vt,s a (/..�?t
Physical Address,City,and Zip
{.i tl ae 21:REMARKS I
t(} ' 'Rr
County Parcel Identification No.(PIN) I
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
Z51 . i5IG5 N o$a LI- a),-z€s w 7— t -2_3
Si offer ieed Well Cmtmctor Date
6.Is(are)the well(s):*ermanent or ❑Temporary By signing this form.I hereby cert(that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 111ilo copy of this record has been provided to the well owner.
if this is a repair,fill out known well construction information and explain the nature ofthe
• repair under 021 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 provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below laud surface: )©OS (ft:) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent((tample-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: (ff.) Division of Water Quality,Information Processing Unit,
If water level is above casin&use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
H
11.Borehole diameter: L9 1 (in.) 24b.For Injection 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: Vt4D 11/i construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground jection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh NC 27699-1636
R.
Cf 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) 95 Method of tesR the addresses)above, also submit one copy of this form within 30 days.of
13b.Disinfection type: Amount: completion of well construction to the county calth department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of WaterQualiry Revised Jan.2013

•
Won Drina°Savit-enout Cardikoden
owner; Or L Pharr , wenAddrem
I hereby certifyihatthe above referenced well was grouted ink in w
ith
all County Well roles.
Well Miter: \)"t t urwr
ions .
Catficate#: \-67 — _ Date
Construcllon W
Total Depth: 005- CIUMPAA
a► S ewt : 'Caging Ytd
Caelog T
: S
Drive
GPM 95