GW1--06183_Well Construction - GW1_20230922

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WELL CONSTRUCTION RECORD - For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: , ,
14.WATER ZONES I i
Josh Plemmons FROM TO DESCRIPTION
Well Contractor Name R. 2 !
4137-A f. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi.caseillwells)OR LINER Of no Iteable)
_ FROM O ���� (.51
Q�I JDIAMETER in. �C � MATERIAL
Clearwater Well Drilling Inc. t Dvc
Company Name 16.INNER CASING OR TUBING(geothermal close$-loop)
E —Z5D2t— FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: �J R. R. ;la
List all applicable well construction permits(i.e.County.State.Variance,eta) ft ft. is
3.Well Use(check well use): 17.SCREEN . J
FROM TO DIAMETER 'SLOT SIZE I THICKNESS MATERIAL
Water Supply Well: ft ft. in
°Agricultural °Municipal/Public 1
°Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) R' ft In 1,
°Industrial/Commercial °Residential Water Supply(shared) I&GROUT TO I
FROht +MATERIAL' EMPLACEMENT METHOD&AMOUNT
°Irrigation 1 ft. Zo ft. 1►.e .1l „--.)(-{flit.
Non-Water Supply Well: ft. R. I;
°Monitoring °Recovery i,
Injection Well: ft. 1'
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applcable) 1
FROM TO MATERIAL I EMPLACEMENT METHOD
°Aquifer Storage and Recovery °Salinity Barrier R. R. i'
°Aquifer Test OStormwater Drainage B. ft.
['Experimental Technology °Subsidence Control 20.DRILLING LOG(attach additional gheets if m ssary)'
°Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color.tattiness,so�lUro b ck ttspe.grain size.etc)
°Geothermal(Herting/CoolingReturrr) ClOther(explain under#21 Remarks) ' iL PI) f't LY�/'�i � ( A'1 N
rt. I
4.Date Well(s)Completed: Well ID# n1 a. � l
kA1 IL 142 it. tAli Le
SD.-Wed Location: ��� lt4Z R. 1�S ft IrI/l�►vt •
JUnu. + 0 s R. ft. .
Facility/Owner Name ' Facility IDI!(ifapplicable)
r� I
?.�r�i O n\ VV ov) Le ft ft- R. R. :.: .1
�,P cal Address,City,and Zip
i p21.REMARKS s y QZ J
County Parcel ldeniificalion No.{PIN) Iitfi.:it- �.y ,
lion:
eat
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2, i
(if well field,one lat/long issuffici
' Sr ' Q°s N 32, 1c �5-s-,of w $-ZZ'Z3
r of Certified Well Contra r Date
6.Is(are)the well(s):Oermanent or °Temporary y si ing this form,I hereby certify that the uell(s) us(here)constructed in accordance
•th SA NCAC 02C.0100 or ISA NCAC 02C.02OO ell Construction Standards and that a
7.Is this a repair to an existing well: °Yes or 4114o - copy of this record has been provided to the tiellon
If this is a repair.fill out i noun well construction htlormation and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this form.
You may use the back of this page to provide ditional well site details or well
S.Number of wells constructed: construction details.You may also attach additi i al pages if necessary.
For multiple infection or non-natersupply wells ONLY with the same construction.you can
submtronafana SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: I " (f) 24a. For All Wells: Submit this form with' 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
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10.Static water level below top of casing: 40 (it) Division of Water Quality,Inform lion Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 115 (in.) 24b.For Infection Wells: In addition to sen ing the form to the address in 24a
ram, rr above,also submit a copy of thisfonn with 30 days of completion of well
12.Well construction method: -((�'Y V� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Undergroun Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: i636 Marl Service Center,Rafe gh,NC 27699-1636
(0 Method of test 2�For Water Supply&Injection Wells: addition to sending the form to
13a.Yield(gpm) the address(es)above,also submit one copy of this form within 30 days of
completion of well construction to the c health department of the county
Amount
13b.Disinfection type: where constructed. !(
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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