GW1--02267_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
I.Well Contractor Information:
Josh Plemmons 14.WATER ZONES I 4
FROM TO DESCRIPTION I
Well Contractor Name R. R. I j
4137-A R• R• j j
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)°RIMER Of applicable)
FROM TO DIAMETER THICKNESS I MATERIAL
Clearwater Well Drilling Inc. rt. ft. .in. I
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
�+ ��\
l FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well construction permits 0.e.Cmury,State.Variance.etc.) R. ft. in.
3.Well Use(check well use): 17.SCREEN i
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. In.
❑Agricultural ❑MunicipallPublic ft.
•Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. in.
❑lndustrial/Commencial ❑Residential Water Supply(shared) 19.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft. I
Non-Water Supply Well:
I. R. I
❑Monitoring °Recovery R. R. i
Injection Well:
°Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
R. ft.
❑Aquifer Test ❑StormwaterDrainage j
I. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary).
❑Geothermal(Closed Loop) ['Tracer FROM TO DESCRIPTION(color.hardness,solUroc type.grain size.etc)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) 0 it' �I' hia(
4.Date Well(s)Completed:3-'7---Z--Well lD# rt. t. jfl5cJ 1I _
5a.Well Location: —. ._. ..,.. : ,r t
(� ft. R. ' rim, .,.1' i`ki I,:V o cc?. -k- Dex"a 1 %-\Y-GZ.c-r ft. ft. , .
Facility/Owner
AName (� Facility ID#(if applicable)
I AliN ea .. 207d
L� i` ambkinq ix e Zc( , Asl aA I• IQ ft. ft. to :,r'. :"t?ry •c g(M
Physical Address,City.and Zip J 21.REMARKS t 't""'':`lZ
County Parcel Identification No.(PIN) /
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cerd a lion: '
(if well field,once latilong is sufficiiee�nt) Q/� I ` l J ' n
cJ�I CM, Vt01XdN 'Ea -54' Lalq W S-20- A-
/twc
of Certified Well Contractor 1 Date
6.Is(are)the well(s):'Permanent or °Temporary ggthis form,I hereby certify that the well(s)was(were)constructed in accordance
5A NCACO2C.0100 or 15A NCAC 02C.0200+Nell Construction Standards and that a
7.Is this a repair to an existing well: °Yes or *4o of this record has beenprovided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#2i remark seclion or on the back of this form. 23.Site diagram or additional well details:
S ^ 3b�C-� Yon may use the back of this page to provid additional well site details or well
8.Number of wells constructed: l construction details. You may also attach add'Tonal pages if nerPcsary.
For multiple injection or non-uritersupply wells ONLY with Ike some construction,you can
submit one farm_ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For AU Wells: Submit this form wi in 30 days of completion of well
For multiple wells list all depths ifdi(fere l(example-3@200'and 210100) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Quality,Info ation Processing Unit,
If water lerel is above caring,use"+" - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit a copy of this'form witl'Jn 30 days of completion of well
12.Well construction method: constriction to the following:
(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
Method of test: 24c.For Water Supply&Injection Wells: addition to sending the form to
13a.Yield
(gpm) the address(es)above, also submit one cop}`of 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 Jan.2013