GW1--02133_Well Construction - GW1_20240409

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells 1
1.Well Contractor Information: ,,
Josh Plemmons 14.WATERZONES I II
FROM TO DESCRIPTION I
Well Contractor Name ft. ft. III
4137-A ft. R. 1 II
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER I THICKNESS I MATERIAL
Clearwater Well Drilling Inc. f ft. 50 ft. �j if I id.
IPie
Company Name 'I6 INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER' I THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft 'i t.
List all applicable well construction permits(i.e.Cormry.State,Variance.etc.) R. ft. it
3.Well Use(check well use): 17.SCREEN I
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ nicipal/Public ft. R. In.
Mu
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT ' 1
FROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
❑Irri lion ft.
rr�11 ft /en ni f/(J
Non-Water Supply Well: l i [ t"171'(y!i t 1 l I I(�(yJ
[Monitoring ❑Recovery R.
Injection Well: R. f• 1' I
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(If applicable). I
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD _
R. ft.
❑Aquifer Test ❑StormwaterDrainage R. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)_
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,Iiatdness,soWrock type,grain size.ctc.) .
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) / R• 57l ft• tSI/ /�1�r�J�.p J.preb r.
4.Date Well(s)Complete¢ dell,ID#G-, T3 R „' //�Tc
5a.Well Location: `ems L" J [c. [t (��11(Xj(Gf�(� Lll�
3Veph2,n 4- or 6 1 obo a7 �'ft �175 R
Facility/Owner Name Facility iD#(if applicable)
131 t outer V'r ttul (2d . Mars [ ( ift «.4•
..
R tt n ",,,
Physical Address,City,and Zip NC 21.REMARKS I i Pp n i+ /irljd
\I n riison inf.:1-:-.:° ,-__
County Parcel Identification No.(PIN) I p.: , ,":-'1 yRr+::'F.(;,.:r
•
t (y ; ry v
5b.Latitude and Longitude in degrees/minntes/seconds or decimal degrees: 22.Certifi 'on:
(if well field,one Iattlong is sufficient) /
35' "1®r on 6"l . p ro
1 N O a,
�� ' 3s.Oa W 7-aV
Si ature of Certified Well Contractor ' I, 1 Date
6.Is(are)the well(s): Permanent or ❑Temporary y signing this form,I hereby cent'that the well(s)r as(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC'02C.0200 W ll Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or Xilklo ' copy of this record has been provided to the kdi owner.
If this is a repair,fill out krroun well construction information and explain the nature ophe
repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
You may use the back of this page tolprovide 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 .-
9.Total well depth below land surface: 30S (ft.) 24a. For All Wells: Submit this form withi 30 days of completion of well
For multiple wells list all depths ifdifferent(eranrple-3@200'annd 2e1001 construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Quality,Inform Ilion Processing Unit,
If water level is above casing,use"+ t 1617 Mail Service Center,Raleigh,NC 27699-1617
I ,^, 24b.For Infection Wells: In addition to sendih the form to the address in 24a
11.Borehole diameter: l!! I� (in.) i g
t^ y/y t above,also submit a copy of this Ifl rm withi{30 days of completion of well
12.Well construction method: t � i aA `-�' construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) • j
Division of Water Quality,Underground injection Control Program,
_ FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
�} ` 24c.For Water Supply&Injection Wells: In I ddition to sending the form to
13a.Yield(gpm) �V��'� � �r1/M/ethod of test 11 the address(es)above, also submit dine copy of this form within 30 days of
l.V -1On t ..K Amount: �'t'0,01)61) completion of well construction to dine
county health department of the county
136.Disinfection type: where constructed.
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Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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well Dater TO Rtmons signed:
certificate#: w-1 7/1- Date
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Total Depth-____a0S-- TYPm-
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Casing Depth! St) Depth: a-0
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