GW1--01123_Well Construction - GW1_20240216

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY: I
1.Weil Contractor Information: 1
Josh Plemmons 14.WATER ZONES i '
FROM TO DESCRIPTION I
Well Contractor Name ft. ft. I i
4137-A ft. ft. ( I
NC Well Contractor Certification Number IS.OUTER CASING(for multi-eased wells)OR MINER(if op Rcable)
FROM 70 DIAMETER THIICKNESS MATERIAL
Clearwater Well Drilling inc. 1 IL 13.3 RI to`I'C ,in. I
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Company Name 16.INNER CASING OR TUBING(geothermal clbseddoop)
' /g(` 2 � I1 VLP FROM f TO «- DIAMETER in. THICKNESS MATERIAL
2.Well Construction Permit#: OSS �{(�QS 1
List all applicable well construction permits(i.e.Cormry,Slate,Variance,etc.)
It. ft. In. j
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑A nculturai fL TL in.
g ❑Municipal/Public
OGeothermal(Heating/Cooling Supply) {Residential Water Supply(single) n «• ir'• I
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18,OM GROUT l
FR TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑In-Wate «. o ft. ,,,, p I�� 1!�
Non-Water Supply Well: e_° l C.
•
❑Monitoring ORecov LTY ft- rt. I
Injection Well: ft. R.
❑AquiferRecharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable) I
FROM TO MATERIAL Storage and Recovery ❑Salinity Barrier I EMPLACEMENT METHOD
ft. ft.
I
❑Aquifer Test ❑Stormwater Drainage
R. R.
❑Experimental Technology ❑Subsidence Control
20.DRiLLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,holiness,soWroek type,grata s►re,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) i «, 3`6 «. 30 fin 1-1 { r;.
4.Date Well(s)Completed: Well ID# It D O f ��� R
R. «.
5a.Well Location:
Vk/� 1- ,� J ft. ft.
I�" CM�4 e M a..mr f\e, IL a. c, g::: a�,)V E all..,
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ALp 3)-GAI Ctvi R. ft. Ftd 1 C. 2Q24
P ysical Address,City,and Zip 1
2I.REMARKSnd
� ��'°
OWC) i'DG
County Parcel Identification No.(PIN) 1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certifi �'on:
(if well field,one laVlong is sufficient)
1 I q
35' i OS, ON . X? W vl—� 1-.-- Io
Signa R''.ICettified Well Contractor Date
6.Is(are)the well(s):)Permanent or ❑Temporary By 141 ng this form,I hereby cer►ijy that the ueell(s) tus(were)constructed in accordance
with 1,A NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Dyes or j(lo copy'Phis record has been provided to the well ouster
If this is a repair,fill out known well construction information and lain the nature of the
repair under VI remarks section or an the back of thisform. 23 Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additi nal pages if necessary.
Far multiple injection or non-water supply wells ONLY with the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form withi 30 days of completion of well
For multiple wells list all depths ff djferent(example-3e200'and 2@I00) construction to the following: i
10.Static water level below top of casing: (_Q 0 (ft.) Division of Water Quality,Inform on Processing Unit,
If water level is above casing,use t 1617 Mail Service Center,Ralei h,NC 27699-1617
�11.Borehole diameter: I .3 (in.) 24b.For Infection Wells: In addition'to sendi g the form to the address in 24a
above, also submit a copy of this form with' 30 days of completion of well
12.Well construction method: 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 Centel,Raleih,NC 27699-1636
13a.Yield(gpm) l Method of test �q` 24G For Water Supply&Injection Wells: In i ddition to sending the form to
the address(es)above, also submit one copy If 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 GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Qualrry Revised Jan.2013

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