GW1--03181_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
14.WATER ZONES
Josh Plemmons FROM TO DESCRIPTION
ft. ft.
Well Contractor Name
4137-A ft. ft.
15.OUTER CASING(for multi-cased wells OR LINER(if ap Iicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. I ft. ")1 ft. \j '1 '' in.
Y
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
C� 1 ��35 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: s J\ it. 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
FROM TO DIAMETER SLOT SIZE -THICKNESS .MATERIAL
Water Supply Well: ft. ft. in.
❑Agricultural ❑Municipal/Public
` L ft. ft. in-
❑Geothcrmal(Heating/Cooling Supply) glKesidential Water Supply(single)
❑industriallCommercial ❑Residential Water Supply(shared) IX.GROUT
FROM TO MATERIAL�(� EMPLACEMENT METHOD&AMOUNT
❑Irrigation \ ft. ,_,A,.:, it. (1��g1\ pC� 1t \'1 auci
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery --
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)__
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer 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)
❑Geothermal(Closed Loop) ❑Tracer FROM TO 1 I DESCRIPTION(color,hardness,sottlroock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I ft' 1'3 1 ft' ri�i C/)�,'1r"�4 mat‘i )
(' l j t 1 ft. -1 f. MCA lJt_�1 1l 1. -
4.Date Well(s)Completed: `f-'J 29 Well ID# *✓ fL g,
1 1 (k6ill ._ .... _
5a.Well Location: ) P0011 CA erS 10Ctt. ft y� ��lj
CrC Ce_ 0-Cal N - ] ft. ft. s
Facility/Ownerac Name Facility
t� Q� (� (�1�,t Facility IDp(if applicable) ft. ft. '1 2` 2024
VC I C W�" ICY+ �^-1.1�+a t, ft. ft. - -.: �'...)4
Physical Address,City, (
,and Zip
21.REMARKS 1_
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifi Lion:
Orwell field,one tat/long is sufficient) i.
N %V q --Jl
Si ure of Certified ell Contractor Date
6.Is(are)the well(s): IN'ermanent or ❑Temporary 'signing this form, 1 hereby cerrh'that the well(s)new(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copyo this record has been provided to the well owner.
7.Is this a repair to an existing well: ❑Yes or � o f
If this is a repair,fill out known well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under i121 remarks section or on the back of this form.
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 same construction,you can SUBMITTAL INSTUC 1 ION$
submit one form. t
9.Total well depth below land surface: 1 J (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3C200'/and 2@100') construction to the following:
10.Static water level below top of casing: LVO (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use
,"+f"', 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: _- I (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
r�����VI above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 Censer,Raleigh,NC 27699-1636
13a.Yield(gpm) 2-C Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
I 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

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