GW1--06161_Well Construction - GW1_20230922

WELL CONSTRUCTION RECORD For[mental use ONLY: '
This form can be used for single or multiple wells
I.Well Contractor Information:
14.WATER ZONES I '
Josh Plemmons FROM TO DESCRIPTION
Well Contractor Name R. ft
4137-A ft• ft. I
•NC Well Contractor Certification Number 15.OUTER CASING(for mu)N.cstsedwells)ORLINER Of all Usable)
FROM TO DIAMETER ! I THI NESS MATERIAL
Clearwater Well Drilling inc. l R- ja R. U0'I 6 i°• p\(c
Company Name 16.INNER CASING OR TUBING(geothermal d loop)
A �c� FROM TO DIAMETER , THICKNESS MATERIAL
V
2.Well Construction Permit#: V a 0 - a R. fL in' I
List all applicable well construction permits(La.County.State.Variance.etc) ft. it. 1m. I
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO , DIAMETER .SLOT SIZE THICKNESS MATERIAL
it. it. in. ! .
°Agricultural °MunicipallPublic
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
R. fL in.
°Industrial/Commercial °Residential Water Supply(shared) 1&GROUT I
FROM TO MATERIAL�+ l'PL11 EMPLACEMENT METHOD&AMOUNT
Obrigatitm I iL 20 R. C ►
( ie - g,e d
Non-Water Supply Well: ft. fL
°Monitoring °Recovery
R. ft.Injection Well
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL all le)
FROM Mam� EMPLACEMENT METHOD
°Aquifer Storage and Recovery °Salinity Barrier R, ft.
°Aquifer Test fStormwater Drainage ft. ft.
°Experimental Technology °Subsidence Control 20.DRILLING LOG(attach additional sheets If necessary)'
°Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color,tininess,salVroerrtype,groin size etc.)
°Geothenual(Heating/CoolingReturn) OOther(explain under#21 Remarks) l R. 5�ej-rL fr�n 4- dirr- -
4.Date Well(s)Completed: Well a. �> ft.L iD# r f j I ,,
ft.
Sn.Well Location: ft. ft. # "( ,3-'i ils
gamt c,U���.,� ft. ft. • - r
Facility/OwnerlI N'' {{ ►{11 II Facility WU(if applicable) ft. ft. i S t P r r I UC3
• Sq C-kb l 1 v, �11 b l If. 1�1c�.rt on �, fL fr. i ,,ciac.7:,i^rl?r•--Ir�aA�9 Urtb
Physical Address,City,and�ip 21.REMARKS a slt Cl::
M cbat/ie-1 l
i,
County Parcel Identification No.(PIN) i
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one fat/long is sufficient)
55. t Q1' 3�5 N ©\ 13- w ...- - 1(-1 _12
Si of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or °Temporary 8 signing this fans.I hereby certify that the well(s) as(acre)constructed in accordance
r al ISA NCAC 02C.0100 or ISA NCAC,02C.0200 Jt Construction Standards and that a
7.Is this a repair to an existing well: °Yes or iliiNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and erplain the nature glare 23.Site diagram or additional well details:
repair under#21 nenmrls section or on the back of this form. age
You may use the back of this page to provide ditional well site details or well
B.Number of wells constructed: constriction details. You may also attach additi I pages if necessary.
For multiple injection or non-water supply wells ONLY with the same consiradimr,you can submit one farm. CI� SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form with' 30 days of completion of well
For multiple wells list all depths if different(example-3Q22000'and 2©l00') construction to the following:
I.
10.Static water level below top of casing: © (ft.) Division of Water Quality;;Info tlon Processing Unit,
If wafer level is above casing,use'+ i 1617 Mail Service Center,Raid h,NC 27699-1617
11.Borehole diameter: L.0 i u (in.) 24b.For infection Wells: In addition to sew the form to the address in 24a
above,also submit a copy of this form with" 30 days of completion of well
12.Well construction method: raVO•rt4 construction to the following:
(ie.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground jection Control Program,
FOR WATER SUPPLY W LLS ONLY: 1636 Mall Service Method of test: Center,Raid h,NC 27699-1636
24c.For Water Sunaiv&Iniectioa Wells: In addition to sending the form to
13a.Yield(gpm) i� the address(es)above,also submit-one copy f this form within 30 days of
I3b.Disinfection type: Amount: compl�taf wdcte l construction to the county health department of the county
ereForm GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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