GW1--06185_Well Construction - GW1_20230922

I
WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons 14.WATERZOIQFS i
FROM TO DESCRIPTION
Well Contractor Nam it. ft
R. ft. I 4137-A
_ i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)ORLINER(if app lieabte)
FROM TO DIAMETER - THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 Lob- R. t D.tl a,ia. pvc
Company Name 16.INNER CASING OR TURING(geothermal doted-loop)
2.Well Construction Permit it EAA /1 3�� FROM TO DIAMETER THICKNESS MATERIAL
l^^I R in,
List all applicable well construction permits(I.e.County,State.Variance.etc.)
IL ft. In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE- THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it. R. In.
❑Geothermal(Heating(CoolingSupply) ResidentialWaterSupply(single) ft. R. In.
❑lndustrial/Commercial ❑Residential WaterSupply(shared) 18.GRow'
FROM TO MATERIAL EMPLACCMENT METHOD&AMOUNT
❑irrigation 1 R. 6i.� it- (l,,,�„ ,,,/.� ad
Non-Water Supply Well: Y�1
R. rt.
❑Monitoring ❑Recovery
Injection Well: R. R.
❑Aquifer Recharge OGrntmdwater Remediation 19.SAND/GRAVELPACK pfappucable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL; I EMPLACEMENT ni
R. R I
❑AquiferTest OStotmwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) l]Ttacer 20.DRILLING LOG(attech'additional sheets if necessary) .
FROM TO DESCRIPTION(calor,buidaesa,solVrocktype,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) t R• ( 0 R' t l,la C-
-6 --
tt. f. rap,
4.Date Well(s)Completed: Well ID# +-tqL Oft- l��lXJI n
Sa.Well Location: ( �.�C
}�/ �y �/ R. ft. C J�/�Ip i p
s 1 /1 J��1`! .1 �r1.L�1"1'is a R. ft. I !+--' ,,I --gym : -t0:
FF iilliityy/Ownner Na_mee Facility iDfi(if applicable) Z'� - _l
I1 Course, . R. R.
at
R. R. I SEP 2 r 2023
Piraqical� dds,City,and Zip 21.REMARKS it%�J'
L1/iTYi'v. t a N•bl.:g V 1�
D4.GrpOG
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certifies r on:
(if well field,one latflong is sufficie
a51,91'5a 5c0 N ' I(3'
33. lea W 3-2) a3
Si I. of edified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By s'+•ing this form,I hereby certify that the wells)n (were)constructed in accordance
with NCAC 02C.0(00 or I5A NCAC 02C.0200 11 Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or tylo • co, aphis record has been provided to the Drell omen
If this is a repair.fill out known well construction information afd explain the nature ofthe I.
repair wider#21 remarks section or on the back oflhis form. 23.Site diagram or additional well details:
You may use the back of this page to provide itional well site details or well
8.Number of wells constructed: construction details. You may also attalch'additi 1 pages if necessary.
For multiple injection or non-wafersupply wells ONLY with the same construction,you con
subnriloneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: r 4 5`.- (ft.) 24a. For All Welts: Submit this form within 30 days of completion of well
For multiple wells list all depths ijcbjferent(example-3@200'and 2®l00') construction to the following I'
10.Static water level below top of casing:to y 1.�0 (ft.) Division of Water Quality l informs on Processing Unit,
If water level is above casing,use"r+' ` 1617 Mail Service Cent}r„Raleig ,NC 27699-1617
II.Borehole diameter. O (in) 24b.For Infection Wells: in addition to sending the form to the address in 24a
12.Well construction method: rPiabove,also submit a copy of this form within 30 days of completion of well
construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground 14ijection Control Program,
FOR WATER SUPPLY WELLS ONLY: /^� 1636 Mail Service Center,Raleig NC 27699-1636
13a.Yield(gpm) 14 Method of test: 94ci 24c.For Water Supply&Infection Wells: In a dition to sending the form to
the address(es)above,also submit orie copy this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county ealth department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of WaterQuality Revised Jan.2013
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