GW1--01752_Well Construction - GW1_20240320

_"" I For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name rt. ft.
4137-A ft. ft. •
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If up 5 liable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. / n. Li ft. (I%t/0 in. ���
Company Name 16.INNER CASING OR TUBING(geothermal cloned-loop)
�J FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: �0,�j 3 w boo 3 ) R. ft. in.
List all applicable well construction permits(i.e.County.State,Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE, THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R. R. In.
❑lndustrial/Commercial ❑Residential Water Supply(shared) IL GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation / R. ^0 ft. (/f) ,, t � e
Non-Water Supply Well: �( (�
R. R.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier It. n.
❑Aquifer Test ❑Stormwater Drainage
0 Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,soil/rock type,grain size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 FL
f q 7 ,w 6a !f/i I- c�tF
4.Date Well(s)Completed: Q,� Well ID# ft. ft.
p /,�� ft. ��Jan, ( �
5a. I Location: k�"t I �,i T C(/ ft. ft.
G1i C Cz2CG QcddaE
ft. �y
ft. ( V f /4(/!C
Facility/Ow r Name Facility iD#(if applicable) R. n. f 5
n. ft.
Ph,y0 al Address.City,and Zip 21.REMARKS 5 t;';h• 9 0 l r1%
County Parcel Identification No.(PiN) hlk r;••r: ''1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: iN.�"i
22.Certifj n:
(if well field,one lat/long is sufficient) �7
J35 50'2S. V3 N 3'<n t Wl oS(,i, al W ) -S,2(1'
LL11 Si of Certified Well Contractor Date
6.Is(are)the well(s): gyf'ermaaent or ❑Temporary By going this form./hereby certl&that the well(s)rims(Isere)constructed in accordance
wi I SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or tio copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information an explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
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 additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. q SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: / (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a@100'and 2@100') construction to the following:
10.Static water level below top of casing: t6t 0 (ft.) Division of Water Quality,information Processing Unit,
If wotcr level is abase casing,use"+" f/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12 Well construction method: /7/7
/ above, also submit a copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY W LLS ONLY: � 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: ii /j &Iv 24c.For Water Sum &Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of 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 GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013