GW1--00671_Well Construction - GW1_20240125

Nett IT 2
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I.Well Contractor Information:
Josh Plemmons 14.WATERZONES I I J
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I I
4137-A 't, I. I I
NC Well Contractor Certification Number IS.OUTER CASING(for multi-essed wells)OR LINER(If ap licable)
FROM TO DIAMETER I: THICKNESS MATERIAL
Clearwater Well Drilling Inc. t t:. 'l a �. f l 0,ti.3 . I
Company Name t��/ �/�J 16.INNER CASINGOR TUBING(geothermal rldsed-loop) ���
OSS ^ U(OV13' I SS`7 FROM TO DIAMETER in. THICKNESS MATERIAL
2.Well Construction Permit#: jl
List all applicable well construction permits(i.e.County,State.Variance etc.)
ft. ft. fIL I
3.Well Use(check well use): •17.SCREEN !
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agricultural DMunicipal/Public H. R In•
❑Geothermal(Heating/Cooling Supply) /tesidential Water Supply(single) I' n' in. I I'
❑lndustrial/Commercial ❑Residential Water Supply(shared) FROhf IS.GROUT I
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation i ft. r>9\ ft.
Non-Water Supply Well: \ (�i f 0� Ns
❑Monitoring ORecovery it. it.
Injection Well: ft. IL P
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)'
DAquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD -'
rr. ft. I
❑Aquifer Test DStonnwater Drainage
OExperimental Technology ['Subsidence Control ft.
R. I I
['Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if neee:sexy).
FROM TO DESCRIPTION(color,btrdoess,soiCrock type,grain she,ere.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ( n• 1 9 oft. t x x n'p l
�� +c�
L '�I-
I
4.Date Well(s)Completed: Well ID# •a(()R. I 8q. troi Ii` ►(
5a.Well Location: QIL 0 ft. a Q
2OZo vi 1c1�r s )�02 eft. (�r e O,
Facility/OwnerName £ Gr -r ,1„ X , ''
! ® Facility ID0(if applicable) 9' °°"
• r d 2 L
I. I. J N 5 2074
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN) I t- b w':i
'La
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifica' r '
(if well field,one lat/longg is sufficient)/ �` 3t 1.11J
n
C `�J( )r� 0 .ci LY N () U , W � �- a -/3-.; ,3
Si ofCertified Well Contractor Date
6.Is(are)the wel(s): ermanent or ❑Temporary
By.tgning this form.1 hereby certify that the,wells)a (were)constructed in accordance
tilt 13A NCAC 02C.0100 or ISA NCAC 02C.0200 W I1 Construction Standards and that a
7.Is this a repair to an existing well: [Yes or pit copy of this record has been provided to the nail owner.
llthis is a repair,fill out know,well construction information a d e lain the nature of the
repair under#21 remarks section oron the back of this form. 23.Site diagram or additional well details:a
You may use the back of this page to provide acditional well site details or well
S.Number of wells constructed: construction details. You may also attach additio 1 pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: CY '! S (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdgferent(example-3(d0,�0'and 2@I00) construction to the following: I
( V
10.Static water level below top of casing: `Y (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,aislie""n+", 1617 Mail Service Cente 1,Raleigh,NC 27699-1617
11.Borehole diameter. Ls, (in) 24b.For Injection Wells: In addition to send, the form to the address in 24a
above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: VD1 C XL. construction to the following.
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground I jection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleig NC 27699-1636
13a.Yield(gpm) 4-.DO Method of test: 24c.For Water Supply&Iniection Wells: In a dition to sending the form to
1 the address(es) above,also submit onell copy o this form within 30 days of
$13b.Disinfection type: Amount: completion of well construction to the county ealth department of the county
where constructed. C
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality) Revised Jan.2013
i
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Well Maw SOLGreat C.rdi anion
V
Own= 202-0 9-oo‘ldr,s moot
Addiew 205 T„ � 1-�P r,� Repahv,
p ()5S - cOa
I1 , yt tt€e above referencedweBwasg milinappe in
with
allComtyWell=lex .
Weil Diger '-(Ter) P1ec `o •
Ce+ct ca ; k4.4 Dab: : . - . .
Constin lam 4_
Total Depth; . r A-
g' ?V It ),i 0
CagingDePth: 4 a0 ao
Diameter: lP'`i
Height
DireShoe: -
GPM: cW