GW1--06080_Well Construction - GW1_20230921

861
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
Josh Plemmons 14.1ATERZONES I : I
FROM TO I DESCRIPTION
Well Contractor Name R. R.
4137-A ft. fL 1
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NC Well Contractor Certification Number 15.OUfER CASING(far.multi-cased wells)ORLINER(If so tieable)
FROM I TO I DIAMETER CKNESS MATERIAL
Clearwater Well Drilling Inc. } ft- rib f. I to?, In' I I
Company Name 16.INNER CASING OR TUBING(geothermal eibsed-foop)
FROM TO DIAMETER Ttl CKNESS MATERIAL
2.Well Construction Permit#: (..... - ci 3 - ' 7 8' R. fL I in.
List all applicable well construction permits tie.County,State.Variance,etc.)
fL ft. ' in.
3.Well Use(check well use): 17.SCREEN •
_ i
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipalPublic ft. ft. in
❑Geothermal(Heating/Cooling Supply) Stesidential Water Supply(single) ft. h' In.
❑lndustrial/Commetcial ❑Residential Water Supply(shared) 18..CROUT TO I
FROM MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 'Y�PAY lei
Non-Water Supply Well:
20 X m
❑Monitoring ❑Recove ry It. R' r
Injection Well: fL ft. I
❑Aquifer Recharge ❑Groundwater Remediation 19.SAIt l/GRAVELPACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
R. ft.
❑Aquifer Test ❑Stoonwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets ifnebessary)
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRIPTION(color.birdmen,
birdae ,"solUrack type.grain size.Ma)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (, ft• '7 I.0 i,• o-'la` 1V lod- r'+
4.Date Well(s)Completed: Well MN `� 4 J �r� i 7�,
it ft
5a.Well Location: ft. it.
J. Pharr fr. R. .
Facility/Owner Name Q •�,� L�FacilityIDO(ifapplicable) »r•�•%
1� I live s1 r�Jr. IL ft. i7Z ,r ,j' ,i li
Physical Address,lefty,and Zip 21,REMARKS 0 C sr ti I n 1 j
nd�on JLP
Conn ty Parcel Identification No.(PIN) - .c„n I,rs>
i kNb( `"c'';c'11 tr`Yl
��� .•'-
5b.Latitude and Longitude in degrees/mInuteslseconds or decimal degrees: 22. cation: -5
(if well field,one tat/long is sufficient)
ICI .(Pb, LP3N a' 1411r93,1I W - 7-5-23
si o edified Well Contractor Date
6.is(are)the well(s): Permanent or OTemporary g signing this rm.I hereby tern that the w e!!s
fa ly () (were)constructed in accordance
n lb ISA NCAC 02C.0100 or ISA NCAC 02C.0200 l Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l)o copy of Mk record has been provided to the well owner.
Ifthis Is a repair.fill out known well construction Information and explain the nature ofthe i
repair under VI remarks section or on the back of this farm. 23.Site diagram or additional well details:
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 pages if necessary,
For multiple infection or non-water supply wells ONLY with the same construction you can
submit one farm. , , SUBMITTAL INSTUCTIONS
s—�
9.Total weft depth below land surface: i T G J (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(2200'and 2(:)l00') construction to the following: j
10.Static water level below topof casin • Division of Water g. (ft.) Quality,Information Processing Unit,
filmier level is above eosin&use"-"l(� 1617 Matz Service Center,Raleigh,i NC 27699-1617
�f
11.Borehole diameter: (hI.) 24b.For Infection Wells: la addition to send" the form to the address in 24a
y� �.f above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1 l) ( construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Quality,Underground I Jection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleig,NC 27699-1636
i
13a.Yield(gpm) Method of test: L9 24e.For Water Sultrily&Infection Wells: In a dition to sending the form to
the addresses)above,also submit one copy o this form within 30 days of •
13b.Disinfection type: Amount: completion of well construction to the county ealth deportment of the county
where constructed.
Form GW I North Carolina Department of Environment and Natural Resources-Division of Water QualityRevised Jan.2013

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Well Driller$.1f-Si ut Cadawden
o :
Aaron51 . River E .prz
I hereby ceriifythat the above referenced well was grouted in appearance in v
ith
all couatyWellroles.
wen nxHtex;
Josh -Pke vnooS s a:
..
c 5cate#: y-(31-A
constructicar Grout
Total Depth; 71 LI-5 _ 'I/Pm
Casing 7eype V T idmes min• Casing
Depth: Deptb: i 1
Mangler: LI.yg
Height
Drive Shoe:
GPM: y +, .
4