GW1--03691_Well Construction - GW1_20240618

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 applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
t 1��'I(����� FROM TO DIAMETER THICKNESS - MATERIAL
2.Well Construction Permit#: 1St�Vt vR. 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.
DAgricultural OMunicipal/Public
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
Lllndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation ft. H.
Non-Water Supply Well: --
ft. H. I
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
[I Aquifer Storage and Recovery ❑Salinity Barrier -
ft. It.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under I/21 Remarks) 0 H. 3r-[)ft. C 1�, --H-\eI ri-- [
ft. vv ft. y�
4.Date Well(s)Completed:5 _) I Well ID# �'ll
ft. ft.
5a.Well Location: ft. ft.
SCOA+ 4 i\)Q-V EL\ CWHir ft. -_
Facility/Owner Name Facility ID#(if applicable) ^ ��
ft. ft. . L`�J ;
L4 \ C,o W or cl. . n. ft.Physical Address,City,and Zip JI I N l 8 2024
y�� 21.REMARKS
PA)v ee s s� `.,W a 4•ifi rl <^o sem0./Usit
County Parcel Identification No.(PIN) Dtf401 41
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certifl lion:
(if well field,one`latlong is sufficient) / e/
,. - Ulo ,9 ' ,.)L4 JT. S- 7)
Si of Certified Well Contractor Date
6.Is(are)the well(s): erntanent or ❑Temporary B signing this form.1 hereby certh'that the well(s)was(were)constructed in accordance
rich/54 NCAC 02C.0100 or 15A MCA C 02C.0200 Well Construction Startdurds and that a
7.Is this a repair to an existing well: ❑Yes or 1lo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information a d explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
2�O ' _ You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: J Cjr construction details. You may also attach additional pages if necessary.
For multiple injection or non-outer supply wells ONLY with the sante construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For Al Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifd/event(example-3(a2J200'and 2(a.l00') 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 sending the form to the address in 24a
above, also submit a copy of tb-s form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cahle,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&injection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: - the address(es) above, also submit one copy 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 GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013