GW1--00697_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple welts
1.Well Contractor Information:
Josh Plemmons 14.WATER ZONES I I
FROM TO DESCRIPTION I
Well Contractor Name R. ft.
4137-A R. ft. I I
NC Well Contractor Certification Number IS.OUTER CASING(for multi-eased wells)OR LINER Of applicable) '
FROM TO DIAMETER' THICKNESS I MATERIAL
Clearwater Well Drilling Inc. i fr. as- R. ea ye?in. I pve
Company Name 16.INNER CASING OR TUBING(geothermal cldsed-loop)
%�/�(� p �} FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Ot 3 L7 7"7 70 'ry - /€ 931 (I. ft. in. I
List all applicable well construction permits(t.e.County.Stag Variance,etc.)
R. R. i in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R fL in
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. R. In.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT i
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation / R. �1�1 R.
Non-Water Supply Well: GO �e�Yle�lf mr`�vel�
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft. !
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL - I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery °Salinity Barrier ft. R.
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft. i I
20.DRiLL1I4G LOG(attach additional sheets if u4 scary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,blydoess,soWVrock type,grain sire,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks t- R.
) i
�S ft. �7 ft. cS�,l�?a �df if
4.Date Weil(s)Completed: Well U)# 470 IL �7( 't
Sa.Well Location: -7/ R Et,Pt-
&coil L. llzgsh-one l hrste c I ft. U' ft_ Tex/A
Facciilliiitty//OO/Jw er Name Facility ID#(if applicable) �' " ^` *^--
gii 7 �/! a s-- A i
/ rc.r t Q �� ft. R. !I'a L;4.,t' t"` W' P Li
ft. ft.
Physical Address,City,and Zip 4 AN•� '��t')7
c n 21.REMAItICS L
County Parcel identification No.(PIN) r - _ ,7,^, (�;,,,
CANC:j OG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificad :
(if well field,one tat/long is sufficient)
35 '85-1 ql. 7S' N 93 ' ©d 'do_ 03 W v-_ a-7-0?3
Signs of Certified Well Contractor Date
6.(s(are)the well(s):Aermanent or ❑Temporary
By igning this fort,I hereby certify that the well(s) vas(awe)constructed In accordance
with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or gio copy of this record has been provided to the well owner.
if this is a repair,fill out know:well construction information and axplain the nature of the
repair wider#21 remarks section or on the back of this form. 23.Site diagram or additional well;'detalls:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additicnal pages if necessary.
For multiple injection or non-watersuppiy wells ONLY with the same construction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: c5Ci S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi ferenl(example-3@200'and 2@l00') construction to the following: 1
10.Static water level below topof casing: �� Division of Water Quality,Info tion ProcessingUnit,
g. (ft) Q h
If water level Is ohm casing,use"+•• /c, 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diameter: 667 /a (in.) 24b.For Infection Wells: In addition to sendiag the form to the address in 24a
above,also submit a copy of this form withir 30 days of completion of well
12.Well construction method: tV fa-a/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
_ FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Hefei h,NC 27699-1636
t
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: in ddition to sending the form to
the address(es) above, also submit one copy f this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county ealth department of the county
where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013