GW1--06104_Well Construction - GW1_20230921

WELL CONSTRUCTION RECORD
This form can be used forsingle or multiple welts JFor Internal Use ONLY:
1.Well Contractor Information:
i
Josh Plemmons 14.WATER ZONES _I i I
FROM TO 1 DESCRiPi7ON
Well Contractor Name ft. R. I
4137-A ft. ft. I 1
NC Well Contractor Certification Number - IS.OUTER CASING(formula-cased wells)°RU INER(Kap We)
• FROM i TO� I DIA(af/8 I THtCKhFSS MATERIALe Clearwater Well Drilling Inc. � (� � I , , ta. pv�
Company Name r( 16.INNER CASING OR TUBING(Enthrall dased-toop)
2.Well Construction Permit#:a0?Z' Z4-214'-q o I t M To DIAMETER Tilt CKNESS MATERIAL
ft [L j In.
List all applicable well construction permits(le.County.State.Variance elc)
iw ft. I In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
°Agricultural OMtmicipaUPublic ft. R. in
{
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) f' n In. II
Olndustria1/Commercial °Residential Water Supply(shared) 18.GROUT
MitigationF1ROAf TO A MATERIAL ' EMPLACEMEINT METHOD&AMOUNT
Non-Water Supply Well: / t�I U ft- (e�1 � 0
DMonitoring ❑Recovery ft. ft.
injection Well: ft. fr. 1
°Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAYBLPACK(If applicable) +
°Aquifer Storage and Recovery ❑Salinity Ranier FROM TO MATERIAL I EMPLACEMENT METHOD
❑ tferTest R. ft.
�N OStormwater Drainage
it. ft.
°Experimental Technology °Subsidence Control
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets ITnet�ary)
FROM To DESCRIPTION(Colon mcdness,sol Week We.MID slze,etc)
OGeothemtal(Heating/Cooling Return) °Other(explain under#21 Remarks) ft. CAS.- ft U
4.Date Wells)Completed: Well ID# ft. 54 IL
5a.Well Location: . aVY ft-Marve,1 Earn% ►y Pail-ah►p QVsft• -oaf% q (LI i-c'
fL ft.
iFaccility/Owner Name Long
FacclityiDil(if applicable)
W+"li 1 1 S- Long Spt f c e_L 1, ft. ft. t W i ''.7-::it�', t.
Ph ical1 Address,City,and Zip
Yic o,^ 21.REMARKS 'E4 2 l ZLl'1`�
County ) Parcel Identification No.(PIN) Inforrom :f P y
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. a;
Certin one G ":'�. X,'
(if well field,one iet/ong is sufficient)
135tq .S`-N Oq''g0. 1,4, W
5i• lure of Certified Well Contractor Date
6.Is(are)the well(s): [Permanent or °Temporary
By signing this form.I hereby certify Iharthe wells)it (were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 V:I!Construction Standards and that o
7.Is this a repair to all existing well: OYes or Mio copy of this record has been provided to Mewl!owner.
If this is a repair.fill out know,well construction information and explain the nature of the
repair under#2l 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:• tonal well site details or well
8.Number of wells constructed: - construction details. You may also attach additio al pages if necessary.
For multiple injection or non-wutersupply wells ONLY with the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: S (ft.) 24a. For All Wells: Submit this form within c 0 days of completion of well
For multiple wells list aii depths iid t(Crumple-3@200''and2C100) construction to the following:
10.Static water level below top of casing: WO - (IL) Division of Water Quality,(nforma.on Processing Unit,
!riveter level is abovecasing,use"+"( Q. 1617 Mail Service Center,Raleig ,NC 27699-1617
11.Borehole diameter. ( n
w 1 0 (in) 24b.For Injection Wells: In additionto sendin_the form to the address in 24a
above,also submit a copy of this form within :0 days of completion of well
12.Well Construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground 1 ection Control Program,
FOR WATER(gPSUPPLYWELLS ONLY: - 1636 Mail Service Ceater,Raleig NC 27699-1636
13a.Yield m C
) I t/
Method of test b 24c.For Water Supply&Iniectoa Wells: In a titian to sending ihe form to
the address(es)above, also submit one copy o this form within 30 days of
13b.Disiniection type: Amount: completion of well construction to the county h th department of the county
where constructed. I
1
Form GW-1 North Carolina Department ofEnvimnment and Natural Resources-Division of Water Quality Revised Jan.2013