GW1--06043_Well Construction - GW1_20230920

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons FR MATER ZONES DESCRiFnON I - .
Well Contractor Name IL ft.
4137-A ft. ft. P
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased welts)OR LiNZR(if se &able)
FROM TO DIAM R I THICKNESS MATERIAL
Clearwater Well Drilling Inc. l IL a) it. LQ' 'n- i e, .
Company Name 16.-INNER CASING OR TUBING(geothermal dosed-loop)
2 y�l 7 2 - O O/�I FROM TO ,DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0�i J 0`o R- ft. 1n.
List all applicable nail construction permits(e.Counry.State.Variance,etc.) ft. ft. la'
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Mtmicipal/Public
R, ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single} I
❑Industrial/Commercial ❑Residential Water.Supply(shared) 1&GROUT
FROfit TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation I R Z p fL ) 111 rcuo
Non-Water Supply Well: ft. ft.
❑Monitoring °Recovery
injection Well: • iL fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(lf applicable)
FROM TO MATERIAL , EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
['Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) I]Tracer FROM TO DESCRIPTION(wbr,,hardness,��sallkocck type.grain ske.eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ( u' ?jD R' sour-A/ (1 TC Lt i-(
4.Date Well(s)Completed: Well INl `
P IO(Oft. "`��� �n. ( �5a.Well Location: _ �7 ft' i 003-11. 1:�
D \)11AsheenI\� Ur_, IL ft. r7 ,w- 7i i'.7""'7 .
Facility/O Name Facility IINP(if applicable) IL IL I l ` t v 1 i. V �
\22J) t�C'iG, Cr-251' W A IL I I SFP 9 n 2021
7.;altAddress,' 1{'^1City,and Zip 2j 21,REMARKS
l.-+�1 !curn I,C1LiY{'N.36jn.il•C r;::J i+!em t_l'.:.
J �
County Parcel Identification No.(PIN) I UN C:::' .
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certific :
(if well field,one latllong is sufficient)
( D 140` LOS• lS N sat 5q 1 W _- l _3--23
Si of Certified Well Contractor ' Date
6.Is(are)the well(s): [Permanent qY or ❑Tern ore.
P fY B• igning this form,I hereby certify ihar the Wks) sias•(were)constructed in accordance
itth ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Krell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or No copy of this record has been provided to the well ouster
If this is a repair.fill out known n l construction Information an✓d a lain the nature of the y Site diagram or additional well details:
repair under#21 remarks section or on the back of this form. 23You may use the back of this page to provide ditional well site details or well
8.Number of wells constructed: construction details. You may also attach additi i pages if necessary.
For multiple Injection or non•watersupply wells ONLY with the same construction.you can SUBMITTAL INSTUCTIONS
submit oneform.
9.Total well depth below land surface: 1 DOS (ft.) 24a. For AD Wen: Submit this form within 30 days of completion of well
IIf
For multiple wells list all depths dii ferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: C) (ft.) Division of Water Quality',information Processing Unit, -
Ifanter level is above casing,use"+"( 1617 Mail Service Center,Ralei h,NC 27699-1617
II.Borehole diameter: L.Q .i'il (In.) 24b.For Injection Wells: In addition to send g the form to the address in 24a
above,also submit a copy of this form with' 30 days of completion of well
12.Well construction method: construction to the following.
(i.e.auger,rotary,table,direct push.etc.) Division of Water Quality,Undergroun Injection Control Program,
FURWATER SUPPLY WELLS ONLY: n
1636 Mail Service Center,Rale h,NC 27699.1636
Method of test: 1 24c.For Water Simply&Injection Wells: addition to sending the form to
13a.Yield(gem) the address(es)above,also submit one copy of this form within 30 days of
completion of well construction to the coup health department of the county
13b.Disinfection type: Amount: where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013