GW1--02278_Well Construction - GW1_20240409

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
Josh Plemmons 14.WATER ZONES I
FROM TO DESCRIPTION I Well Contractor Name ft. ft. I -
4137-A it. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LiNER(if np livable)
FROM TO DIAMETER. THICKNESS MATERIAL
Clearwater Well Drilling Inc. rt. it. ia.
I
11
Company Name _ 16.INNER CASING OR TUBING(geothermal do#eddoop)
1. FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: ,--1
I-J Dian 1 t ft. ft. in. I
List all applicable well construction permits(i.e.County.State.Variance,etc.)
ft. It. M.
3.Well Use(check well use): 17.SCREEN I
Water Supply Well: FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
fL ft. In.
❑Agricultural OMunicipal/Public
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) H ft. In.
Olndustrial/Commercial OResidential Water Supply(shared) 18-GROUT
FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft. I
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft ft, I
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK Of applicable)• .1
❑Aquifer Storage and Recovery QSalinityBSRjer FROM TO MATERIAL EMPLACEMENTMEIHOD
ft. R.
oAquifer Test ❑Stormwater Drainage It. ft.
QExperimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets If necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color.hataes,solUrockt e,grain,ke tie.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R' (�Do R• qed f'flil l' Cep /}l d-
rt. ft. / /�
( �/�
4.Date Well(s)Completed: Well ID# ft. F����! I ��uh
5a.Well Location:
ft. ft.
Cr'ai o` QI- MeA ihc I SUJe.CLA. _ft,
,�; T,
ft. y �._d.L.:: r rz L)
Facility/Owner Name Facility iD#(if applicable)
3 roct l-cn. 1\5hc-ul lit ft. ,f'R kV. OZ A
.
ical Address,City.and Zip
21.REMARKS � _ arn.�Pa;1R6i LiAtt
'0rir 1,`�,I5;31f 11 gODDb ; it>•s..,.[,.P...DWQ lots 1
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certif:.on:
(if well field,one 1st/long is sufficient)
3Ct t l 'ao .Ss; •wa' 37 ` 3.DI W 3- 20 .d1
Signs •• of Certified Well Contractor I Date
6.Is(are)the well(s):Ikerrnanent or OTemporary By sly ing this form,I hereby certh'that the hell(s)was(were)constructed in accordance
with 54 NCAC 02C.0100 or 15A NCAC 02C.0200.1Ye►l Construction Standards and that a
7.Is this a repair to an existing well: QYes or l No •.y of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature ofthe
repair under#2)remarks section or on the back of fhb arar. 23.Site diagram or additional well details:
3 c) q p0 cc You may use the back of this page to provide a ditional well site details or well
8.Number of wells constructed: T construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the some construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (it.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdifferent(ample-3©200'and 2C100') construction to the following:
I
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 sendi Ig the form to the address in 24a
above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: cdnstruction to the following:
(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 2 769 9-1 63 6
I
13a.Yield 24c.For Water Supply&Infection Wells: In addition to sending the form to
(gpm) Method of test:
the address(es)above,also submit one copy or 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 GW-I North Carolina Department of Environment and Natumi Resources-Division of Water Quality Revised Jan.2013