GW1--03150_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4137-A ft, ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS I MATERIAL ^
Clearwater Well Drilling Inc. ft. ft. in. tl
Company Name t6.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER_ THICKNESS MATERIAL
2.Well Construction Permit#: A,U P •^�� "D V 1 ft. ft. in.
List all applicable well construction permits(i.e.County.State.Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public �—
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. It• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 Irrigation ft. ft.
Non-Water Supply Well:
ft. ft.
0 Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)._�
FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional,beets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION Senior,hardness,salt/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. It.
4.Date Well(s)Completed: 4 —2- Well um
ft. � ft. C /r^li) `lt, � �.-
' (----Le-- ft. ft. L
Sa.Well Location: t '. oU) f— ft. H.
i�,eA -1 81f- .� .. �P 10-.rcl ft. ft.
Facility/Owner Name �^ (1 Facility tD#(ifapplicable) ft (t — r 9A
LP 4-q, 1 CA ) Ut,ue_f` ft. It _ MAY 1
.
i
Physical Address,City,and Zip 21.REMARKS I r.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cert ji tion•
(if well field,cone lat/llongg is sufficient)
Si tore of Certified Well Contractor Date
6.is(are)the well(s): Permanent or ❑Temporary ,By signing this form.1 hereby curt/,that the well(was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.1s this a repair to an existing well: es or ❑No copy ojthis record has been provided to the well owner.
If-this is a repair.Jill out known well construction tnf motion and explain the nature of the
repair under#21 remarks section or on the hack 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 ar:ach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
.5,
9.Total well depth below land surface: . (ft.) 24a. For All Wells: Submit this torn within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2(0001 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"+" 1 1617 Mail Service Center,Raleigh,NC 27699-1617
t(% / 1J 24b. For Injection Wells: In addition to sending the form to the address in 24a
11.Borehole diameter: (in.)
/ -- above, also submit a copy of this lone within 30 days of completion of well
12.Well construction method:
()-Ai-t'14-% construction 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 27699-1636
CA Method of test: !ter /.J 24c.For Water Supply&Injection Wells: In addition 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