GW1--06102_Well Construction - GW1_20230921

1
WELL CONSTRUCTION RECORD For Internal Use ONLY: 1
This form can be used for single or multiple wells j
1.Well Contractor Information:
Josh Plemmons FROM WATER NES
TO DESCRIPTIOON!
Well Contractor Name ft. ft.
4137-A a. n. I 1
NC Well Contractor Certification Number 15.OUTER CASING(for-multi.cased wells)OR ER(if ap !feeble)
FROM TO DIAMETER I THICKNESS MATERIAL
Clearwater Well Drilling Inc. / 2 IL Ll l e;'n• pVC
Company r�72-` 3-1C1 Q �} ( 16.INNER CASING OR TUBING(geothermal dosnl-loop)
-q _l�,t OM . TO ft. DIAMETER i� 17ilgKNESS MATERIAL
2.Well Construction Permit#:lv`
List all applicable well construction permits(i.e.Com*y.State.Variance.etc.) iL ft. in.
3.Well Use(check well use): 17.SCREEN l
Water Supply Well: FROM TO DIAMETER SLOTSIZEI THICKNESS MATERIAL
rt. R.
°Agricultural OMtmicipal/Public ,
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single) rt' ft. in.
°Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO� MATERIAL EMPLACEMENT METHOD&AMOUNT
°Irrigation / ft. Olf/ D. 01ra !7 !J [((id
Non-Water Supply Well: R. R.
°Monitoring °Recovery
Injection Well: rt. tt. '
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Storage and Recovery °Salinity Barrier iL R-
°Aquifer Test °Stomiwater Drainage ft. ft.
°Experimental Technology °Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothemral(Closed Loop) °Tracer FROM TO DESCRIPTION(color,hardness,
/soUIra k type,grain sine,etc.)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) / ft. (9c ft. cr/ a yl C!� !1.
4.Date WeH(s)Completed: Well iD# as Z(�R. IT`' f
570 `. Sal 'L eZtlet`-I1
Sa.Well Location: - �I ft' f R. Ti `l
cedar_ A L c�' C��sbius LLC IM�— r
FacilityIDti tfa applicable) rt, � �'`;��'a •';is J�'�^• r 9'±
Facility/OwnerlVame ( Pp ) ft. iL I '�'*-�""°'1.`i ' 'a" ..
Lv tiNor wait Or. i4 f , 0-0-1 It. ft. S E P 2, , 2023
Physical Address,City,and Zip 21.REMARKS'
JaiiLdsoc lll40:1, ^^51 l��c;r 3 . irj., ..
County
Parcel Identification No.(PIN) Cri.: j--,..r
Sb.Latitude and Longitude in d minutes/seconds or decimal degrees:
b'i egrees/ 22.Certific..on:
(((if��well��field,00ne1st/longissufficiet cl2 �{ / 1#- �]3,�3
W si 31-ofC ified Well Contractor Date
`_L
6.Is(are)the weU(s): ermanent or °Temporary 8 signing this form.I hereby certify thatthe wells)was(were)constructed in accordance
'\ w Jr ISA NCAC 02C.0100 or ISA NCAC 02C.0200 ell Construction Standards and that a
7.Is this a repair to an existing well: °Yes or Olo copy of this record has been provided to the well own .
If this is a repair.fill out known well construction information and explain the nature of the .Site diagramor additional well details:
repair under VI remarks section or an the back of this farm. 23You 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 addi anal pages if necessary.
For multiple injection or non-watersupply wells ONLY with the same construction,you can SUBMITTAL �UCCIONS
submit oneform. p� �y "
9.Total well depth below land surface: l.yo V (ft.) 24a. For All Wells: Submit this form wi 30 days of completion of well
For multiple wells list alldepths if different(example-s@200'and 2@100') construction tothe following:
1Q.Static water level below top of casing: (f) Division of Water Quality,info ation Processing Unit,
If water level is above casing.use"++•` 1617 Mail Service Center,Ralt h,NC 27699-1617
11.Borehole diameter: U (in.) 24b.For lniection Wells: in addition to sea Ting the form to the address in 24a
above,also submit a copy of this
/y form wi 30 days of completion of well
12.Well construction method: l A.r VI • construction to the following: !
(i.e.auger,rotary.cable,direct push,etc.) Division of Water Quality,Undergronn Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Ral lgh,NC 27699-1636
1 ,
il ` 24c.For Water Supply&Injection''Wells: I addition to sending the form to
13a.Yield(gpm) 5 Method of test: �a the address(es)above, also submit'one cop of this form within 30 days of
completion of well construction to the count'health department of the county
13b.Disinfection type: Amount: `
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013