GW1--07283_Well Construction - GW1_20231109

WELL CONSTRUCTION RECORD Far Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons I4 WATE TO R ONES DESCRIPTION 11 I
Well Contractor Name It. ft. I
_
4137-A ft' f`. i
NC Well Contractor Certification Number 15.OUTER CASING(for•mold-cased..'ens)"ORLINER(if applicable)
•
FROM TO DIAM THICKNESS MATERIAL
Clearwater Well Drilling Inc. I ft' 100 ft' ( IT r i°• DVC, - - -
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop) I"
t��n��� f V� �j, FROM
tt. TO • DIAMETER h THICKNESS MATERIAL
2.Well Construction Permit itU\VI �f [r. hi.
Lift all applicable well construction permits(i.e.County,State.Variance.etc.) ft tt. jm;
3.Well Use(check well use): 17.SCREEN - i, -
Water Supply Well: FROM TO DIAMETER_ SLOT SIZE THICKNESS MATERIAL
rt. ft. in. 6
❑Agricultural OMunicipal/Public I.
°Geothermal(Heating/Cooling Supply) KResidential Water Supply(single)
8. rt. in. I.,
Olndustrial/Commercial °Residential Water Supply(shared) l8:GROUT
FROM TO MATERIAL/ntt EMPLACEMENT METHOD&AMOUNT
❑Irrigation I R t f ft- C+ti
' l Ilea (0 ct
. Non-Water Supply Well: tL I.
°Monitoring °Recovery ,,
Injection Well: rt. R. !,
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVELPACK(if applicable)
FROM TO MATERIAL, . EMPLACEMENT METHOD
°Aquifer Storage and Recovery °salinity Barrier n, n,
°AquiferTest °StormwaterDraina8e ft. ,'
°Experimental Technology °Subsidence Control 1
20.DRILLiNG LOG(attach additional sheets if needs'
oCleothennal(Closed Loop) °Tracer FROM TO D N color,hardness,mNrocktype,rrain she*de)
(Heating/Cooling Return) °Other(explain under#2I Remarks) i ft. •�V ft. ` yityk-
0Geothernral4.DateWell(s)Comppineted: Y� n.Well/ID#/j �'� /� ¢`r / /R R' I i
Sa.Well Location: l'1©h �1 i Mot 1�/,'"_' `' OSgit -5 ft. fir �1�{1v vl..K
.tiro Gl ( KAn n Pj e-Y.�. IL ft. r ;:•
Facility/Owner Name (� FaclityID,/(if applicable) _ ?
�.f �.7 ` �� ��'a?.a.��4...�+1•_.,„ S1 ry-"it
LpC we Ec` i' Dr r o 1 tt. it. e'(�
Physical Address,City,and Zip 2LREMARKS i• ' N4'V 1) 9 2123
ifiParcel Identcati N Identification o.(PIN) �'
CountyF OW�,.,,•:,1,;,:
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: t2.Certification: i•
(if well field,one let/long sufficient) t��
r I W it-a3
N ,
Si ofCettified Well Contractor I Date
6.Is(are)the well(s): t)Q1�etmaneat or OTemporary By signing this form.I hereby certify that;the well(s)uus(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 IV l Construction Standards and that a
7.Is this a repair to an existing well: °Yes or [ to copy of this record hiss been provided rothe welt owner.
If this is a repair fill out knows well construction information and lain the nature of the l;
repair wider#2i remarks section or on the back of thisfarm. 23.Site diagram or additional well details:
You may use the back of this page to provide a 'tional well site details or well
8.Number of wells constructed: constmction details. You may also attach additi 1 I pages if necessary.
For multiple Injeaion or non-water supply wells ONLY with the same construction,you can SUBMITTAL 1NSTUCTIONS
submit one firm. �f
9.Total well depth below land surface: 1C (ft.) 24a. For MI We1,s: 5ubmtt lists loran with! 30 days of completion of well
For multiple wells list all depths ifdgerenl(example-3@20f0'nand 22©100') construction to the following:
�K
10.Static water level below top of casing: V (it,) Division of Water Quality,info lion Processing Unit,
If water level is above casing,use"+"i 1617 Mail Service Center,Ralei h,NC 2 769 9-1 617
11.Borehole diameter: LO 18 (in.) 24b.For Injection Wells: In addition to send g the form to the address in 24a
A M ,f above,also submit a copy of this form withi 30 days of completion of well
12.Well construction method: rot(�•l constnrctionto the following.
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground ejection Control Program,
FOR WATER SUPPLY WELLS ONLY: n 1636 Mail Service Center,Ralei h,NC 27699-1636
13a.Yield ictMethod of test 24c.For Water Supply&Iniectio'Wells: In addition to sending the form to
(Span) the address(es)above,also submit lone copy f this fort within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013

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