GW1--06068_Well Construction - GW1_20230921

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WELL CONSTRUCTIO RECORD For Internal Use ONLY:
This form can be used for single or multip wells I
1.Well Contractor Information:
Josh Plemmons FRO"TE TOE DESCRIPTION
Well Contractor Name ft. ft. I 1
4137-A rt. IL 1 f
NC Well Contractor Certification NumbsIS.OUTER CASING(for multi-casedweRs)ORLiNER(If applicable)
_ FROM TO DIAMETER t THICKNESS MATERIAL
Clearwater Well Drillin Inc. / 'L tA�3 'L (p % ,'A- p x
Company Name 16.INNER CASING OR TUBING(geothern elclosed-loop)
. n(�/� 0 47q4...)
//J� FROM .TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 'JJ(� 47 IL IL .in.
List all applicable well construction permits(Le.Count%,Slate.Variance.etc.) ;is
r
3.Well Use(check well use): 17.SCREEN '
Water Supply well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. In.
°Agricultural OMunicipal/Public
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ii, it. in
Olndustrial/Commercial °Residential Water Supply(shared) 18.GROUT
FROM TOe /MATEERRIIALL EMPLACEMENT METHOD&AMOUNT"
°Irrigation / it' I 6 IL (/�r lC-fl f // 1�01 CI
Non-Water Supply Well:
ft. R
°Monitoring °Recovery
Injection Well: 'I' a'
°Aquifer Recharge OGroundwaterRemediation 19.SAND/GRAVEL PACK Of applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Storage and Recovery °Salinity Barrier 2 ft 1
°Aquifer Test OStormwater Drainage
ft. ft.
°Experimental Technology °Subsidence Control
20.DRILLING LOG(atiach additional!beets 1f necessary)'
°Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION ttutor.hardens_,seWreck Ntw Webs size.etc)
°Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) J R. 47 R .�i�LU !C� c.,
. , 14-
4.Date Well(s)Completed: Well ID# 73 ft. 37/ R l),ai le
13(1 It. 37 ZiL ` i'
Well Location: Q l� klOOdf
7 ft. tL �.. �,_-°•n; q
Facility/Owner Nam FaclitylDil(if applicable) �
Lan r 1 ; - ,'r,.... ..t�4: 71
Phy i i Ad .City,and Zip 2L REMARKS- J ' r ' 2�
County Parcel identification No.(PIN) C 'ill"' � j;t1A I.:0 '
5b.Latitude aid Longitude in de minutes/seconds or decimal degrees: 22.Certifies _
(if well field,one lat/long is sufficient) r 13,
23
1 Signs .� of Certified Well Contractor' ;' Date
6.Is(are)the well(!): �Perntane t or °Temporary By:igning this form.I hereby terrify that the r+v11(s)was(mere)constructed in accordance
//�� with 1 SA NCAC 02C.0100 or 1SA NCAC O2C.0200 Well Construction Standards and that a
7.Is this a repair to an existing w II: °Yes or. Ci copy opals record has been provided to the well owner.
If this is a repair.fill out known well can!ruction information mr6explain the nature of the i
repair under#21 remarks section or on t a back of this form. 23.Site diagram or additional well detallar
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 it jection or non-watersopp +wells ONLY with the same construction,you can SUBMITTAL INSTUCTIONS
submit One j/�
9.Total well depth. below land s ce: LIDS 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells lio ail depths if ' t(erample-3Q200 •and 22(a;100) construction to the following: .
10.Static water level below top o casing; /// (ft.) Division of Water Qaalii ,Information Processing unit,
If outer level is above casing,use"+" , 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. al 4 (in.) 24b.For Infection 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: construction to the following.
(i.e.auger,rotary,cable,direct push,etc • i
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS NLY: (� •
1636 Mail Service Curter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: I / 24c.For Water Supaiv&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: Amount: completion of well construction to the county health department of the county
where constructed. i
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revisedlan.20I3

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I hereby ,- ,1 that the above referenced well WM grouted in appearance In madame wish
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Certificais 57
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