GW1--01126_Well Construction - GW1_20240216

WELL CONSTRUCTION RECORD '
This form can be used for single or multiple wells For Internal Use ONLY:
1.Well Contractor Information: I
Josh Plemmons 14.WATER ZONES
FROM TO DESCRIPTION I -
Well Contractor Name ft. It.
4937 A H. ft
NC Well Contractor Cenification Number 15.OUTER CASING-(for multi-cased wells)OR LINER(If ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. / ft I 673 ftlif 78 in. I pvt ~" .% g
Company Name �+ 16.INNER CASING OR TUBING(g_eothermalO oop)
�[} 202.3
(•1 l)h �Q C;�� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: W ft, ft. I in.
List all applicable well construction permits(i.e.County.State,Variance,etc.)
ft. ft. In.
3.Well Use(check well use):
17.S
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural °Municipal/Public r• in.
°Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R• ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IL GROUT I
FROM TTO� �
MATERIAL y�,y EMPLACEMENT METHOD&AMOUNT
°on-Wale 4 rt AD h' ee / e dT M%meo,
Non-Water Supply Well:
°Monitoring °Recovery ft. ft.
Injection Well: ft. ft.
OAquiferRecharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) i
°Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
ft. ft
°Aquifer Test DStormwater Drainage
°Experimental Technology °Subsidence Control ft. It.
OGeothernral(Closed Loop) DTmcer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION Valor,Nodal"salUroek type,unto size,etc)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) / ft• C.3 ft �S t� ¢I !L/r�
4.Date Well(s)Completed: Well ID# 3 ft �/ / 11. ^�J •��
�f.Well Location: 57yf- sip (t .rot P DXLII
LPw s �' 4 Nia r e, Me Cc i I - sso ft 46. ft. ro,/ititi(ft ft. I
Facility/Owner Name Facility IDt1(if applicable)
i540 1tS Min . Qc1 �k6 a 5 , ,
.
ft ft ,
Ph ical Address,City,and Zip
n �n 21.REMARKS r EiI re j0_,
County Parcel Identification No.(PIN) tfh'Y:Fi-nriwti;ly�'rr,cos s:,g UM5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: tr`dd►►aa yn�
22.CertiC lion:
(if well field,one latllong is sufficient)
tom' 3?'®2.7 N f? 't5"(3°010.t:36 W A....-- i_aw -a y
`' Sigma ofCertified Well Contractor Date
6.Is(are)the well(s): IYPertttanent or °Temporary By •igning this form.1 hereby cent&that the irell(s))vs(were)constructed in accordance
`` nth ISA NCAC 02C.0100 or ISA NCAC 02C.0200 WI'll Construction Standards and that a
7.Is this a repair to an existing well: °Yes or I io copy of this record liar been provided to the well owner.
If this is a repair,fill out known well construction information and plain the nature of the
repair under 02i remarks section or on the back of this font,. 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 additiokal pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. ) SUBMITTAL INSTUCTIONS
(_C/10
9.Total well depth below land surface: 5 ((I,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3C)200'and 2@100') construction to the following:
10.Static water level below top of casing: (fL) Division of Water Quality,Informa ion Processing Unit,
If water level is above casing,use" � 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: r✓A E (in) 24b.For Infection Wells: In addition to sending 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: rithltu construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.) d Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Reteig}t,NC 27699-1636
. I
I 24c.For Water Sunnis,&Injection Wells: In addition to sendingthe form to
13a.Yield(gym) a Method of tesk
the address(es) above,also submit onel copy o'this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

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casingType-SW pC Thies: . mum
casingDepthl 073 : - o?b
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