GW1--06048_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 1FRO tATERZ TO
DESCRIPTION
Well Contractor Name f ft. C
4137-A ft. it.
NC Well Contractor Certification Number 15.OUTER CASING.(forrmniticasedwells)ORLINSROfap licabte)
• FROM DIAMETER I THICKNESS i MATERIAL
Clearwater Well Drilling inc. / f (7 IL (g 7 i1• t C
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
90� f /� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ft: V V R. ft. in.
List all applicable hell comtroction permits(Le.Connry.State.Variance,etc.) R. ft. in.
3.Well Use(check well use): 17.SCREEN '
Water Supply Weil: t FROM TO DIAMETERIn. SLOT SIZE THICKNESS MATERIAL
ft. R.
❑Agricultural ❑Municipal/Publc
❑ rm Geotheal(Heating/Cooling Supply) Residential Water Supply(single)
R. ft. In.
❑ladustrial/Commercial ❑Residential Water Supply(shared) 18.CROUT '
FROM TO MATERIAL EMPLACEMENT 61p110D&AMOUNT
ft./ ' U R- y17)L /n/gP
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
injection Well: f ft.
°Aquifer Recharge ❑Groundwater Remediation 19.SANDiGRAVEL PACK Of applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery v OSalinity Barrier p. R
❑Aquifer Test ❑Stotmwater Drainage ft.
❑Experimental Technology °Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color.har/Iness,pWracktype,grain sta.etc.)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) / Q ih
1� t ,*
4.Date Well(s)Completed: Well 1D# (� n, 507
7 ft- /� I
(Jt
5a.Well Location: qUS� itinsp 607 fr. (/p.5'ff !am,/Hi
L't2s-/� Try firs ) ft. ft. I
Facility/Owner Name/7 / Facility iD#(if applicable) 2 • i---i -,4--p-. 7--.,€'
n, rt.
Ph�°1 Address,City,andZip 21.REMARKS - S!_N ) 9 LUZ3
/3wk2om/ 0l2/1iQ03i21002
County Parcel Identification No.(PIN) 1D(0;tR'',P.%T.n c'1 c:4-u:'. L f:di
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificc lion:
(if well field,d,onene fat/long issufficient) �} �JQ `f C� 7-9_ J3
W '5Il3/ N U� 'al / 7 • / ` W - �'1
Si two of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or °Te ra
ry y signing this form,I hereby certify that the well(s)r44ns(were)constructed in accordance
with ISA NCAC o2C.0100 or 1SA NCAC 02C.0200 Jr II Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been provided to the well owner.If this is a repair,fill out known well construction information explain the nature of the .Site diagram or additional well details:
repair under OZI remarks section or on the back of this form.
You 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 al pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can SUBMITTAL 1NSTUCTIONS
submitonefomt.
9.Total well depth below land surface: l.V 05-- (ft.) 24a.For All Wells: Submit this form withi 30 days of completion of well
For multiple wells list all depths i(different(example-3©200'and 2©100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,?Information Processing Unit,
Ifnnter level is above casing.use'+''}• • 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: t.Y (In) 24b.For iniectian Wells: In addition to s ' g the form to the address in 24a
�Q�� above,also submit a copy of this form withi 30 days of completion of well
12.Well construction method: Gl construction to the following:
(i.e.auger,rotary,cable direct push,etc.) Division of Water Quality,Underground jection Control Program,
FOR WATER SUPPLY WELTS ONLY: 1636 Mail Service Center,Ralei h,NC 27699-1636
•
Method of test: 6., 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) 3 the address(es)above.also submit one copy f this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013