GW1--00674_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form caabe used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons 14.WATER ZONES
FROM TO DESCRIPTION I
Well Contractor Name ft. ft.
4137-A ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(formnld-cased wells)OR LINER(if ap lfcable)
FROM TO DIAMETER I THICKNESS MATERIAL
Clearwater Well Drilling Inc. / ft' 6j'Q i1, ii. Skki!
Company Name 161NNER CASING MUSING(geothermal closed-loop)
¢� FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: U � 2,3 4. (Q� fL ft.
in
List all applicable welt construction permits(i.e.Counry,State,irariance,etc.)
ft. IL is
3.Well Use(check well use): 17.'SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THiCKNESS MATERIAL -
❑A cultural ft. ft. In. i
❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) tsidential Water Supply(single) n• R. in. I
❑lndustrial/Commercial 17Residential WaterSupply(shared) IS:COM ROUT TO - f1 1
FR MATERIAL ' EMPLACEMENT METHOD&AMOUNT
❑LTigation a
/yam f /} �
Non-Water Supply Well: / ft. 0ef.-401. ')/:VI
❑Monitoring ❑Recove rY R
Injection Well: ft. it.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
❑Aquifer Storage and Recovery 17Sa11nityBartier FROM TO MATERIAL EMPIACEMENTMETHOD
R ft.
❑Aquifer Test ❑Stormwater Drainage .
ft. D.
❑Experimental Technology ❑Subsidence Control
2o.DRILLING LOG(attach additional sheets if necessary)
L1Geothetmal(Closed Loop) ❑Tracer
FROM TO DESCRIPTION(calor.haldneetssalltrotk type,Brain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1ft.qD ft• SOP(
'7 54. 1-f
4.Date Well(s)Completed: Well ID# Ob it. / j(� R. Q /�/l„/l����
5a.Well Location: //v y R. /05 l � i
/05-ft. ,S ft, n�Gl ,iii,!
&02o Adder( �
FacilitylOwner Name Facility ID#(if applicable) -� �'
?i31 7�.� /t %d ft. I �nr► , ���
Physical Address,City,and Zip 21.REMARKS ihZ.rrT„<:„ .�
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certitieati0
35 38 "V i 70 N Ea 3c � 9 t 41'7w ,f /� 2� 3
Signal fCettified Well Contractor I Date
6.Is(are)the well(s): I ermanent or ❑TempOrery By s' Ing this form.l hereby cerlify that the I''miffs)sr (were)constructed in accordance
\ with ISA NCAC 02C.0I00 or ISA NCAC 02C1.0200 WMQ Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or No copy of this record has been provided to the well owner.
If this is aeepair,fill out known well construction information nd explain the nature of the
repair under#21 remarla section or on the back of thisform. 23.Site diagram or additional well details:
You may use the back of this page to provide aJdifional well site details or well
S.Number of wells constructed: construction details. You may also attachadditio I I pages if necessary.
For multiple injection or non-water supply wells ONLV with the same construction,you can 1
submit one form. (/ SUBMITTAL INSTUCIIONS
9.Total well depth below land surface: T� (ft.) 24a. For AU Wells: Submit this form within 0 days of completion of well
For multiple welts list all depths Ifdfferent((tample-3Q200'and 2 tt 100') construction to the following:
10.Static water level below top of casing: 0 (ft.) Division of Water Quality,Inform on Processing Unit,
If viler level is above casing.use
'••+n•"/ 1617 Mail Service Center,Raid ,NC 27699-1617
II.Borehole diameter: 11/ /4 (in.) 24b.For Infection Wells: In addition to sendin the form to the address in 24a
above, also submit a copy of this form within 0 days of completion of well
12.Well construction method: construction to the following 1
(i.e.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
4I ,
13n.Yield(gem) 07.5--- Method of test: 24c.For Water Simpiv&Injection Wells: in addition to sending the form to
the address(es)above, also submit one Icopy o this form within 30 days of
13b.Disinfection type: Amount; completion of well construction to the county h th department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality , Revised Jan.2013

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