GW1--04106_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons FROW1tATERZONES TO DESCRIPTION
ft. n.
Well Contractor Name
4137-A _— ft. ft.
:IS.OUTER CASING(for multi-cased wells)OR LiNER(If IICa te)
NC Well Contractor Certification Number
FROM I TO l DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft, ft. 1 In,
Company Name 16,INNER CASING OR TUBING(geothermal closed-loop)
l COCA —FROM
R TO DIAMETER
to TNiCKN6S8 MATERIAL
2.Well Construction Permit ft:: 1 'OO
List all applicable well construction permits(le,County,Stale.Variance,etc.) --- in, ~
fl. H
3.Well Use(check well use): 17.SCREEN
PROM TO DIAMETER SLCITSIZ6 THICKNESS MATERIAL
Water Supply Well: ft. ft. la.
❑Agricultural ❑Municipal/Public _____ —
n. ft. in.
y(Geothermai(Heating/Cooling Supply) ❑Residential Water Supply(single) _ -
❑lndustrial/Commerciat ❑Residential Water Supply(shared) 18.GROUT
FROM TO [ MATERIAL — EMPLAUMRN T METHOD&AMOUNT
°Irrigation ft. ft.
Non-Water Supply Well: R. ft.
❑Monitoring ❑Recovery —'
Injection Well: ft. ft.
0 Aquifer Recharge ❑Groundwater Remcdtation 19,SA t cRAVEL PACK if a ylkable
PROM KiCallIM MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery OSalinity Barrier ft, ft.
❑Aquifer Test ❑Stormwater Drainage ---
ft. R.
0 Experimental Technology ❑Subsidence Control 28.DRILLING LOG(attach adillatZ�-sheet!ifmeassar )
OGeothermal(Closed Loop) ❑'£racer MOM TO MKS tarns rksibus�t,,,+suM,"tync atn'be,eta)
OGeothermal(Heating/Cooling Return)rn� °Other(explain under f121 Remarks) 0 n' ��SZ.' ft' �'��Q//.'f)(rr/) /I �1-e
1 'd �_ n. It. I Y- gar)4'
4,Date Well(s)Completed. We111D# ft. it.
So.Well Location: n. ft.
SOALe,` --PJ\o,rL Ern lie - ft. rt.
Facility/Owner Name aciiity 1Dft(if applicable) r-- It ft. -
d1/4-1-0 flu\k,k-) Ricky, I r. 1-16n6o-scrvit-f-t. it. ,
Physical Address,City,and Zip I� 11_REMARKS
1-�' Ids\s an --. - .ram
Cnune)r Parcel Identification No.(PIN) • Viti'.,Jdcoli
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees! 22.Cer .
(if well field,one let/Mng is sufficient)
(-I �-I-t '' I.0.al.t� N ga ' 1 ,. (:,, pc): w
Sig re of Certified well Contractor Date
6.is(are)the well(s): Permanent or ❑Temporary signing this form,I hereby cerlI)y that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Conatnrciton Standards and that a
7.is this a repair to an existing well: ❑Yea or t'o copy at this record has been provided to the well owner.
17 this is a repair,fill out known well construction information and lain the names of lire 23.Site diagram or additional well details:
grepair under#21 remarks section or on the hack of this form.
33-0
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 n cessary.
For multiple injection or non-water supply wells ONLY with the sane embtrtredon.you con
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (rt-) Ca. Si-...- All Wells, Submit this form within 30 days of completion of well
For multiple wells lit/ail depths If dyfferent(example-3(+}.200'and 2 r®100') construction to the following:
10.Static water level below top(Wowing: (ft.) Diviston of Water Quality,information Processing Unit,
1f water level is above casing,use^}" 1617 Mall Service Center,Raleigh,NC 27699-1617
II.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 within 30 days of completion of welt
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 Center,Raleigh,NC 27699.1636
I3a.Yield(gpm) Method of test: 24c.Or Water SUDDIy&lnleetloii Wells, In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13h DisinfectionAmount:_ completion of well construction to the county health department of the county
1 where.constructed.
Form(1W-I North Carolina Department of Environnsnt arut Natural Resources-Division of Water Quality Revised Jon.2013