GW1--01757_Well Construction - GW1_20240320

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
Josh Plemmons 14.WATER ZONES - -f
FROM TO DESCRIPTION I
Well Contractor Name ft. ft.
4137-A it. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft. ft. in. -
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
n 1�� �I O D-1 O� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 14: i(`,l ft. it. ;n.
List all applicable well constntclion permits(i.e.Counts.Stale,Variance.etc.)
ft. ft. in. -
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑A ticultuntl ft. ft. in.
g ❑Municipal/Public 4
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
`
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
IRON! TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft.
Non-Water Supply Well:
-
❑Monitoring ❑Recove D' it. ft.
Injection Well: (t. ft. '
❑ qut er Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
DAquifer Test ❑Stormwater Drainage _
ft. it.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etr.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (� ft. 3�i ft. cieD4 I hY n YK. Q
ft. ft. t9J 'I c ' 5� /
�I
4.Date Well(s)Completed: Well ID# t/✓
ft. ft.
5a.Well Location: LOlS Htri,S Lill-
ft. ft. -r�•``'`.
JL \. Q5. \-:--1 cur ri S �MAK 0 [021
ft. R. J
Facility/Owner Name Facility ID#(if applicable)
ft. H. .,e_,.. 4nci I.
I E4 \.ucIcr, V t Stu Way A-rcl(f K.Y ft. +' ` `'' . ,)c
P sical Address,City,and Zip 21.REMARKS Y�1J 3
�tanCom 1-- _, Q L )L}- l S lt?4000000
County Parcel Identification No.(PIN)
n
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certif) on:
(if well field,one lat/long is sufficient)
C35r I-.1 i � 1061 N Tp3` moo` 31 .0p w ,2 -07-a y
of Certified Well Contractor Date
6.Is(are)the well(s): (*ermanent or ❑Temporary
B signing this form,1 hereby certi'that the ate/I(s)was(were)constructed in accordance
15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or , No /,Ith
opy of this record has been provided to the well owner.
It this is a repair,fill out known well constnictinn information and explain the nature of the
repair under#21 remarks section or on the back of this farm. 23.Site diagram or additional well details:
3/13 v I 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 additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
P.Total wctl 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@200•and 2@I00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
filmier level is above casing,use '+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within130 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rosily,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
tab.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Fort G1v-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013