GW1--07275_Well Construction - GW1_20231109

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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. ft.
4 I '
4137-A ft. ft. I
NC Well Contractor Certification Number 1S.OUTER CASING(formuld-cased wells)OR LiNER Of ap liable)
FROM TO DIAMETER; THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft" ‘91)n ( O`1 IIa. I PvG
Company Name 16.INNER CASING OR TIMING(geothermal ddsed-loop)
i L5( �J1 FROM TO DIAMETER' Tn{CKNFSS MATERIAL
2.Well Construction Permit#: IL,- 1l/VI UI IL It. I. in.
List all applicable well construction permits(i.e.County.State.Variance,etc.) iL I in
3.Welt Use(check well use): 17.SCREEN 1
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.: I
OAgricultural DMunicipal/Public
OGeothermal(Heating/Cooling Supply) �tesidential Water Supply(single)
fL ft, Ini
OlndustriaUCommercial OResidential Water Supply(shared) FRORCMT TO MATERIAL EMPLACEMENT MET OD&AMOUNT
Olnigation 1 ft" ap it. �� �f�(1(►1"�►- i�Ti W!
Non-Water Supply Well: ft. n• '"�'' •�
OMonitoring ORecovery
Injection Well: O• a•
DAquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
FROM 70 MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery !]Salinity Barrier n, B, r
DAquifer Test OStormwater Drainage R. ft. ! I
°Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets If necessary)
DGeothermal(Closed Loop) DTracer FROM TO DESCRIPTION(color,turdoess,aontroek Pe.manta size,etc.)
DGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) •1 ft. ' ;N rt. , a* ,��4
It q IL i
4.Date Well(s)Completed: (W�e`ll�/ID# 4 T 1 ,1 t 1 R,
Sa. all Location: J or YQ�r/W`l�(� 't4 1 `i C tL icA ^_
r;J� VCiI ft. ft. �1'1`%I p� a'L a (c..f't4_ r �f r
1 mrny v
F litylOwfierN a Facility IDS(if applicable) R.
ft. iL j
Pthnical Ad z,City,and Zip 21.REMARKS i • " ' X..1-,''-_ ''
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifcati 1;•
(if well field,one laUloo issufficient i q'Q' n q-3-a23
T Signa/-,_
eiledWellContractor; Date
6.Is(are)the well(s):ki.ermanent or t remporary By ;_log this form.I hereby cerifit that the well( was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NOW 02C.02 Well Construction Standards and that a
7.Is this a repair to an existing well: °Yes or t;Vo copy of this record has been provided to the well on r.
If this is a repair.fill out known well construction information anclisplain the nature of the ",
repair under 021 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provddg additional well site details or well
S.Number of wells constructed: construction details.You may also attach ad bona!pages ifnecessary.
For multiple injection or non-water supply wells ONLY w'iththe same construction you can SUBMITTALINSTUCTIQNS j`
submit oneforni. (�
9.Total well depth below land surface: 5`� (ft) 24a. For AU Wells: Submit this form wi in 30 days of completion of well
For multiple wells list all depths if dijferent(example-3Q200 and
( 00 22@I ) construction to the following:
Lam/
10.Static water level below top of casing: (ft.) Division of Water Quality,info ation Processing Unit,
if water level is above casing.use"+"1 1617 Mall Service'Center, eigh,NC 27699-1617
11.Borehole diameter: la 'S (in.) 24b.For Injection Wells: In addition to se ding the form to the address in 24a
12.Well construction method:
PEAW/Ut
above,also submit a copy of this,form wi I in 30 days of completion of well
construction to the following:
(i.e auger,rotary,rabic,direct push,etc.) Division of Water Quality,iUndergrou4d Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Infection Wells: In addition to sending the formto
13a.Yield(gpm) Method of test: V„.4
the address(es)above,also subinit one ' of this form within 30 days of
e• Amount: completion of well construction to the cou ty health department of the county
13b.Disinfection
tyP • where constructed.
Form OW-I North Carolina Departrnent of Emiromnent and Natural Resources—Division of Water Quality Revised)an.2013

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