GW1--06065_Well Construction - GW1_20230921

WELL CONSTRUCTI N RECORD For internal Use ONLY:
This form can be used for single or multi'le wells
1.Well Contractor Information:
Josh Plemmons 14.WATERZONES
FROM TO DESCRIPTION
Well ConnactorName R. R,
4137-A it. °•
NC Well Contractor Certification Numb 15.OUTERCASING(for•multleasedweLLa)ORLiNER(Ifap licable)
FROM T DIAMETER THICKNESS MATERIAL
Clearwater Well Drillin Inc. j D R•
in: c��-.PP i
Company Name
16. R CASING OR TUBING(geothermal dosed-loop)
6S n — O45110
FROM TO DIAMETERNG(geothermal
< THICKNESS MATERIAL
2.Welt Construction Permit#: e:a v [k it ill.
List all applicable well construction permits(i.e.County.State.Variance.etc.) is
3.Well Use(check well use): 17.SCREEN •
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
R. R• In.
❑Agricultural °MunicipaUPublic ,
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R' n la.
°lndustrial/Commercial °Residential Water Supply(shared) 1&GROUT.
FR011f TO MATERIAL EMPLACEMENT M OD&AMOUNT
❑Irrigation , ft ab R. (Ie l A )i— M(\,7(
Non-Water Supply Well: I IX t r i r
°Monitoring °Recovery it ft.
Injection Well: R. R.
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVELPACK tlf applicable)
OA uifer Storage and RecoveryOSalini Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
q g ty ft, ft.
°Aquifer Test OStormwater Drainage •
R, ft.
°Experimental Technology °SUbsidence Control 20.DRILLING LOC(attach additional sheets if necessary)'
°Geothermal(Closed Loop) OTiacer FROM TO DESCRIPTION(color,hareonsloolyrocktype.grata sire.etc.)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 1 R• .'►0n R MID 4 l_Y1( —
it'
4.Date Well(s)Completed: Well ID# 'NW ft' IJO' it. i' 1
Ca.Well Location: i
Facility/0 rName Fir Mitt R. J
\ oci( . t_OLiAL (
ft. ft.
physical Address,City,and Zi 2t.IIEMARKS _
SFP HcuAuod ?, 1 2023
County Parcel identification No.(PIN)
5b.Latitude and Longitude in de tees/tninutes/seconds or decimal degrees: i w`'"'`°�"�0G `°1�r
33(if well field,one fat/long is sufficient) I r ,Ft) IC)(Q.44
�( + 22.Certifi lion: (j 'i�(` 'eta ?
` Si: • of Certified Well Contractor Date
6.Is(are)the well(s): �Permane.t or OTemporary 8 signing this form.1 hereby certify that the ruell(s)errs(were)constructed in accordance
v IUr ISA NCAC 02C.0100 or ISA NCAC.
02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing w iI: DYes or to copy of this record has been provided to the well owner.
If this is a repair.fill out known well co•'ruction Information and explain the nature of the
repair under#21 remarks section or on I e 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 supp .wells ONLY with the same construction you con
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land su ace: (ft.) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii , t(example.3(@200'and 2@t00') construction to the following:
10.Static water level below top o casing: (...12 0 (ft.) Division of Water Quality,1nformation Processing Unit,
If water level is above casing,userr'•+" 1617 Mail Service Center,
ter,Raleigh,NC 27699-1617
11.Borehole diameter: \0 \ (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:ff
�7 above,also submit a copy of this form within 30 days of completion of well
I 1 l� construction to the following.
(i.e.auger,rotary,cable,direct push,etc) 1
I
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY W ELtSS NLY: - 1636 Mail Service Center,Raleigh,NC 27699-1636
ib\ci
13a.Yield(gpm) 3o I Method of test 24c For Water Supply&Iniection(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 county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Q ality Revised Jan.2013
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