GW1--02263_Well Construction - GW1_20240409

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used forsingle or multiple wells
1.Well Contractor Information:
14.Josh Plemmons FROMATERZ TO ONES DESCRIPTION I I
Well Contractor Name ft. ft. I l
4137-A ft. ft. I ;
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased'wells)OR LINER(if ap lieable)
FROM TO DIAMETER •THICKNESS MATERIAL
Clearwater Well Drilling Inc. C ft. - ft. tO1 SS ini I '(PVC,
Company Name 16,INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 20 2-33 - O O ` ('l R. ft. hi
List all applicable well construction permits(Le.County,State,Variance,etc.) in.
3.Well Use(check well use): 17.SCREEN l '
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ,esidential Water Supply(single) ft. ft. in.
❑lndusttial/Commercia► OResidential Water Supply(shared) 18.GROUT
FROtif TO MATERIAL� � A EMPLACEMENT METHOD&AMOUNT
Obligation 1 ft. 3 0 ft, CC�y 1C N UAL?
Non-Water Supply Well:
ft. R. I
❑Monitoring ❑Recovery
Injection Well: ft, ft. I
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable). I
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquffer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,sall/rack type,grain size,etc.)
�- sop '❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 ft- 1-J (��*f(t' L , � '�
t.
t.
4.Date Well(s)Completed: Well ID# 54 f L �5 (t. Mier 111 Litt
JClo, Cor��1-vs -con C(t lQO9t1r I
5a.Well Location: `PSr-ift, --10S(L 1 -rir l, I
Lugs t"M roS c\ ft. ft. U
Facility/Ownn{er`�Name Facility ID#(if applicable) ft. it. _
1 41.0,t 1 V" t k ref,\ H. ft. t:.;1` .—,' i. ci r, �)
Physical Address,QV, �`ljn,and Zip 21.REMARKS I
9C10 r�rK ci to 2024
County Parcel Identification No.(PIN) I c.-
Longitude in degrees/minutes/seconds or decimal degrees: ! 'W Q._�
5b.Latitude and
� 22.Cer�ficatien: Gi v�;�.,�(3
(if well field,one tat/long is sufficient) ` '.
35' 50on' �-,OZ N UZ 4V' -ilo .:`-l/� w -..-t 3- -Z�1'
Si!t tum of >rtified A I Conine or Date
6.Is(are)the well(s): Oermanent or OTemporary By 1,ring this form,I hereby certify that the well(s)I'as(mere)constructed in accordance
wit SA NCAC 02C.0100 or ISA NCAC 02C.0200 IV ell Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or o copy of this record has been provided to the well outer.
If this Is a repair,fill out knotty well construction.information an explain the nature of the I
repair under#2l remarks section or on the back of this farm. 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 wells ONLY with the sante construction,you can SUBMITTAL 1NSTUCTIONS
submit one form.
9.Total well depth below land surface: —1 0-5-
(ft,) 24a. For All Wells: Submit this form withi 30 days of completion of well
For multiple wells list all depths ifdifferent(eratnple-3@200'and 2@I00) construction to the following.
I
I0.Static water level below top of casing: WO (fL) Division of Water Quality,lInformation Processing Unit,
!fuzzier levels above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: lQ 1 ,
t% 24b.For Injection Wells: In addition to sending the form to the address in 24a
` (in
�� _ � above,also submit a copy of this fotin'withi�30 days of completion of well
12.Well construction method: -i construction to the following: 't
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: + i
i (/Z Method of test' t at 24c.For Water Supply&Infection Wells: In ddition to sending the form to
13a.Yield(gpm) the address(es)above, also submit one;copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
•
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
i