GW1--07274_Well Construction - GW1_20231109

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form ran be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons 14.
OM ONES DESCRIPTION
Well Contractor Name B' ft.
4137-A ft. ft.
NC Well Contractor CentScatian Number 15.OUTER CASING(for multi-cased wells)OR ER(if ap Ucable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. \ ft, ‘�Jl./f` t D.`�':�I°' PUG
Company Name. 16.INNER CASING OR TUBING(geothermal hosed-loop)
2.Well Construction Permit ft: a( I45(.O FROM
ft. TO
ft. DIAMETER T)iiCKNESS MATERIALin.
List all applicable well construction permits(i.e.County.State.Variance,eta) ft. ft. In.
3.Well Use(check well use): 17.SCREEN I
Water Supply Well: FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
°Agricultural OMunicipal/Public n id.
OGeothennal(Heating/Cooling Supply) idential Water Supply(single) ft. it. In.
Olndustrial/Commercial °Residential Water Supply(shared) 18.GROUT I
FROM TO r C.c `�-^MATERIAL�(� ( EMPLACEMENT METHOD&AMOUNT
❑Irrigation l ft. `�p R. 'I ( 1 C I
Non-Water Supply Well: 1 1
°Monitoring °Recovery
injection Well: ft. ft.
°Aquifer Recharge ['GroundwaterRemediation 19.SAND/GRAVEL PACK Of applicable) i
°Aquifer Storage and Recovery °Salinity Barrier FROM n. TO MATERIAL E111PLACEalENTMETHOD
°Aquifer Test OStormwater Drainage R ft. • I
°Experimental Technology °Subsidence Control 20.DRILLING LOG(attach additional sheets iflneeeuary)
OGeothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(eolor:.hnrdaess,soflraek typA grain size.tie.)
['Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) •1 Q. ` iL a I,n a-i-�`r -
4.Date Wells)Co 1 Well KW
1. 44,.R. x�_-�^i�
5a. Location: JD( V/J�r ��. �. �,
1lA m Wvl K�f ft. ft. '.': ' --
F '6ty/Owdet N e Facility IDIF(if applicable) R. ft. ..f'n,._ r t- j - i
VD) lai fld e n. INOV 9 2023
Pihyfical Ad s,City,and Zip 21.REMARKS i
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificati;;
(if well field,onetat/lon is sufficienti•
as' ad (33. pi ' ' 15' 4-%'q LP w 4-6_ 9'-,3-;3
TSigma Well Contractor; Date
6.Is(are)the well(s):, Permanent or + temporary By irg this form,I hereby cortify That the wells)loos(were)constructed in accordance
With ISA NCAC IOC.0100 or ISA NCAC 02C.020b Well Construction Standards and that a
7.is this a repair to an existing well: °Yes or o copy of this record has been provided to the well owner.
If this is a repair.fin out known Well construction information an plain the nature of the
repair under H21 remarks section or on the back of-dialer'''. 23.Site diagram or additional Well details:
You may use the back of this page to provi a additional welt site details or well
8.Number of wells constructed: construction details.You may also attach ad 'tional pages if necessary.
For multiple injection or non-water supplyuells ONLY with the same construction.you can
submit oneform. SUBMITTAL INSTUCTIONS 1
9.Total well depth below land surface: 505 (it,) 24a. For All Wells: Submit this form wi in 30 days of completion of well
For multiple wells list all depths['different(example-3@200and 22@100) construction to the following:
�
10.Static water level below top of casing: O (ft.) Division of Water Quality,infotination Processing Unit,
If enter level is above casing,use"+", Q 1617 Marl Service',Center,Raleigh,NC 27699-1617
11.Borehole diameter: l) (in.) 24b.For Iniechtm Wells: In addition to sending the form to the address in 24a
L above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1►�(�Vlf� construction to the following: I
(i.e.auger,rotary,cable,direct push,etc.) f
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service!Center,Raleigh,NC 27699-1636
I
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13a.Yield(gpm) Method of test; 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es)above,also submit one coliy of this form within 30 days of
completion of well construction to the county 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 Ian-2013

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