GW1--06066_Well Construction - GW1_20230921

WELL CONSTRUCTIO RECORD For Internal Use ONLY:
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This form can be used for single or multip e wells
1.Well Contractor Information;
Josh Plemmons Faaoni T TER O DESCRIPTION
Well Contractor Name ft. <Z 1 ,
4137-A ft. . ft.
NC Well Contractor Certification Num 15.OUTER CASING(fot muld-Nsedwells)OR LINER(if ap liable)
FROM TO DIAMETER - THICKNESS 'MATERIAL
Clearwater Well Drillin inc. / ft. 7 7 ft. r/(o 1s'°. (1vc,
Company Name 16.INNER CASING OR TUBING(geothermaiciosed-loop) /"
tt(7 1 �, FROM TO DiAMErER THICKNESS MATERIAL
2.Well Construction Permit#: beis - V� . ..,0 ft. ft. 1.
to.
List all applicable well constructionperm2s(Le.County,State.Variance,etc.) ft. • In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE T ICia7ESS MATERIAL
ft. ft. to.
°Agricultural °MunicipaVPublc
ClGeothermat(Heating/Cooling Sup fly) J4esidential Water Supply(single) R• rt. in.
°Industrial/Commercial °Residential Water Supply(shared) IS GROUT
FROM TD MATERIAL EMPLACEMENT METHOD&AMOUNT
°Irrigation f it. tg 0 f'' !pima-/ G - m J it/(f
Non-Water Supply Well: ft. ft.
°Monitoring °Recovery
injection Well: R' ,
°Aquifer Recharge °GroundwaterRemediation 19.SANDIGRAVELPACKOraanikable)•
FROM TO MATERIAL , EMPLACEMENT METHOD
°Aquifer Storage and Recovery °Salinity Barrier ft. ft.
°Aquifer Test OStotmwater Drainage ft. R.
❑ExperimentalTechnology °Subsidence Control '
20.DRILLING LOG(attack additional streets It necessary)
°Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color,hardness,eelVrocktyp Mtn
ln sbr.etc.)
ta°Geothermal(Heating/Cooling Rein) °Other(explain under#21 Remarks)' 1 re* 7-7ft• (s-ce, a �/_4` i -/ ,
4.Date Well(s)Completed: WeilID# -77 ft. 1 tpi R. 6,ra 2./
l(81,1t, /01 it. e qua
Sa.Well Location: ) /e ` OcR Iej
ChW1�}S4 \6C \k)a S !ft.ft. R. 6'c�- _ _
Facility/Owner Name ,//�p-j/�i Facil• ID#(if applicable) R. _.b *� r
()not 1 an r lb1 ) ) l IV C (G fL t ��3 �. fi�.
Physical Addtes.City,and Zip 2l.REMARKS ,l E P d 1 2023
1-V9ADOOd
County Parcel Identification No.(PIN) ,, .vrfr yi,
5b.Latitude and Longitude in d ees/tninutes/seconds or decimal degrees: 22.Certifica' n:
(if well field,one tatRong is suffrcie f
35' ao Styli )fA GA 015 :cIV W -3 --(23
Si ofCertTed Well Contractor ; Date
6.Is(are)the weU(s):.Iifermane t or OTemporary By (wing this form,I hereby certify that the uell(s)was(were)constructed in accordance
wit ISA NCACO2C.0100 or'15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing w 11: DYes or )Yo copy of this record has been provided to the well ownrer.
((this is a repair.fill out known well co 'ruction information and explain the nature of the
repair ender ill remarks section or on e back ofthisfam. 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 sup ly wells ONLY with the same construction you can SUBMITTAL FAL 1NSTUCTIONS
submit one farm. ((�}} j
9.Total well depth below land su ace: ZDJS (ft.) 24a. For AU Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths iid r t(eranrple-3@200^and 2@l00') construction to the following: ,
10.Static water level below top o casing: ll)0 (ft.) Division of Water Quality,information Processing Unit,
If;toter level is above casing.use"+•' `` 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: VOkalk-- above,also submit a copy of this;form within 30 days of completion of well
I construction to the following: I
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: D 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l Method of test: yq 24c.For Water Supply&Infection 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: I Amount: completion of well construction WI the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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