GW1--02261_Well Construction - GW1_20240409

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1
WELL CONSTRUCTION RECORD '
• For Internal Use ONLY:
This form can be used forsingle or multiple wells
1.Well Contractor Information:
Josh Plemmons 14tWATPsRZONES I 1
FROM TO DESCRIPTION I
Well Contractor Name ft. ft. I ;
4137-A ft. •ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for rnultt.cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Welt Drilling Inc. / it ffF ft &V fin. I /)VC
Company Name 16 INNER CASING OR TUBING(geothermal dared-loop)
J� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0� t(J3�� ft. ft. In.
List all applicable well construction permits(Le.County.State,Variance.etc.) ft. ft. In.
3.Well Use(check well use): 17 SCREEN i -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ClAgricultural ❑Municipal/Public ft. ft. In.
❑Geothermal(Heating/Cooling Supply) Xkesidential Water Supply(single) IL ii• in.
171ndustrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FRObi TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation / ft !ID ft. ?i�1�1, /
Non-Water Supply Well: 4Y C /l PU i ./d�L
ft. ft.
❑Monitoring °Recovery
Injection Well: ft. It.
°Aquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) I
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
n. ft
❑Aquifer Test ❑StotmwaterDrainage ft. iL
DExperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach'additional sheets If necessary)
❑Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color,hardness.sell/reek t)ie,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) / ft. ft 6-an Cl ,/—
4.Date Well(s)Completed: Well ID#
/g ft. /90 ft `j am'fi
/q� ft /q.7 It / TC
5AAaWe0 Location: ` / r g.)� 05-ft* „ aiu
k
1-h olLs- (.;CYI'�t !'l Lt ft. iL A.9 ,.-
Facility/Owner Name Facility ID#(if applicable) Lk " j""°•V.
is
'7'7 Dr teal' id. It. ft.
Phys. I Address,City,and Zip At,„ a ua �r//
�jj � 21.REMARKS r,4 t v 61 t.u2 r
' LI/�[ '
County Parcel Identification No.(PIN) l D t, Z
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certif on:
(if well field,one 1at/long is sufficient)
aS'5-3' 07.C 9aN RP '35' 31. /r W 1it- ----- 3-i 9- zif
S. of Certified Well Contractor Date
6.Is(are)the Well(S): Permanent or ['Temporary signing this form,I hereby cell*that the well(s)1 vas(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Tell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or JILIN° copy of this record has been provided to the'wall owner
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the track 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply webs ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: CS (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdifferent(example-3(/20JJ0''�and 22100') construction to the following: !
10.Static water level below top of casing: (U lJ (ft.) Division of Water Quality!,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleih,NC 27699-1617
11.Borehole diameter: l..0 t r (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
j� 1 above,also submit a copy of this Zinn within30 days of completion of well
fv�i-
12.Well construction method: / construction to the following I
(i.e.auger,rotary,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) `A Method of test 24c.For Water Supply&Infection 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 tile 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