GW1--02264_Well Construction - GW1_20240409

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or nmltiple wells
1.Well Contractor Information:
Josh Plemmons 14.WATERZONES I i
FROM TO DESCRIPTION I , I
Well Contractor Name ft. ft
4137-A ft. ft. I , I
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased'wells)OR LiNER(if ap livable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft. ft. in. I
Company Name 16.INNER CASING OR TUBING(geothermal closell-loop)
'n FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: V 31 D I Ca KILOft. ft. in. l
List all applicable well construction permits(le.County,Stale,Variance,etc.) .
ft. ft. in. I
3.Well Use(check well use): 17.SCREEN •
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
OAgricultural ❑Municipal/Public it. ft. in.
AGeothermal(Heating/Cooling Supply) [Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft.
Non-Water Supply Well: '
ft. ft.
❑Monitoring °Recovery _
Injection Well: ft. ft. I
❑Aquifer Recharge ClGroundwater Remediation 19.SAND/GRAVEL PACK Of applicable) I
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO
To ft. MATERIAL EMPLACEMENT METHOD
f
❑Aquifer Test ❑Stormwater Drainage
fI. ft.
DExperimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necdssary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sot Frock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) d it. l/ ft. npe©
-1�- ft. ft. `�t)1)k CL 5a_ CJ
4.Date Wells)Completed• Z Well ID# ft. ft
Sa.Well Location:o Dan
I� �,� ft. ft. I
,- 1 J(J(.if 1 t"Il', •o . ff. ft. 15t '1 ; "-.;y--•rt,1
i .n
Facility/Owner Name F •lily 1D#(if applicable) R. R. - • -.a it
33 M- A P\. Qr. ► V ,A e\A I IQ. R. ft. ; AP 9 ibli
P ical Address,Ci ,and Z�p 21.REMARKS .
p intuirr•:s..••il %:ter,URI
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce fication: '
(if well field,one lat/long is sufficient)
3s' 3q- ' ,qS N %a' nor SD.401 w -i..--- i(----------- - i-3-2-4
7a1ure
of Certified WellContractor + Date
6.Is(are)the well(s): Permant:nt or (]Temporary ii this farm.I hereby certtt&that the wells)tr (were)constructed in accordance
ISA NCAC 02C.0100 or 15.1 NCAC 02C.0200 m iii Construction Standards and that a
7.is this a repair to an existing well: °Yes or l4No • copy of this record has been provided to the well owner.
If this is a repair.JIH out known well construction information and explain the nature ofthe
repair under#21 remarks section or an the back of thisform. 23.Site diagram or additional well details:
(1 You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: -C-1- construction details. You may also attach additional pages if necessary.
For multiple injection or non-stater supply wells ONLY with the sante construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 014 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf djrent(example-3C200'and 20001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition'to senditlg the form to the address in 24a
above,also submit a copy of this fordo within 30 days of completion of well
12.Well construction method: construction to the following: I
(i.e.auger.rotary,cable,direct push,etc.) I
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection Wells: in addition to sending the form to
the address(es)above, also submit one copy Jr 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 OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised tan.2013