GW1--04119_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: 14•WATER ZONES
Josh Plemmons FROM TO DESCRIPTION
It. ft.
Well Contractor Name
4137-A ft. Ft.
15.OUTER CASING(for multi cased wells)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO// DIAMETER THICKNESS MATERIAL
/ ft. l Ju_It. /' %C�? in. I pi,'
.
Clearwater Well Drilling Inc. C l/l
16.INNER CASING OR TUBING(geothermal closed-loop)
Company Name h/ - 1 1 FROM TO DIAMETER_ THICKNESS MATERIAL
2.Well Construction Permit#: r 0C 0 7 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
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: ft. ft. In.
❑Agricultural DMunicipaltl'ublic
ft. ft. in.
OGeothermal(Heating/Cooling Supply) [Residential Water Supply(single) _
FR
Cllndustrial/Commercial ❑Residential Water Supply(shared) FROMCROUT To MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation / ft. _20 ft. l C e-Me/J ,/)- j7}•77G1 d
Non-Water Supply Well: ft. ( ft.
❑Monitoring ❑Recovery ft ft.
Injection Well:
OAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier it R.
OAquifer Test ❑Stormwater Drainage D. it.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soilrock type,grata size,etc.)
ft. /a ft• 1 )L-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) c- S(('/ �6 C
/05-ft.
/9,7 ft. (1/�.-omr l4
4.Date Well(s)Completed: Well(D# !97ft. /Q? ft- Z1"-Gr'(1t
5a.Well Location: /1 79 r iI. , �,5—ft. /';✓j( t�
�1/-''-h — Cons -lu07on ( .omL7QIu� ft. R.
Facility/Owner Name Facility ID#(if applir le) ft. ft.
FD
/ / 1 cry ,6 ii�� ft. — ,
Ph R
= n,, .
,1j
sisal Address,City,and Zip 21.REMARKS AL IJ�L 1 2 2024
I i nCC be
County Parcel Identification No.(PIN) 11'�Q:76i4i'A 3+ti:'41UT,iI
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cert.'re 'on:
(if well field,one IaUlong is sufficient) Z
I
t /67 r /0 N ( / t (/� `�c W Si na of Certified Well Contractor Date
6.Is(are)the w'ell(s)>Permanent or ❑Temporary signing this form,1 hereby certify.,that the well(s)has(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy /his record has been provided to the well owner.
7.Is this a repair to an existing well: Mires or o No1
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#?I remarks section or on the hack of this form.
You may axe t 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 INSTUCTiONS
submit one form.
� Q _
9.'Tota!well depth below land surface: cifJ vl'� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifjerent(example-3tg200'and 2(0}/00')
construction to the following:
(Y tJ (ft) Division of Water Quality,Information Processing Unit,
10.Static water level below top of casing:If water/erel is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
� 24b.For Injection Wells: In addition to sending the form to the address in 24a
l 1.Borehole diameter: `-'/, / °) above, also submit a copy of this form within 30 days of completion of well
12.Well construction method:
t(titi construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
Aq 24c.For Water Supply&Injection Wells: In addition to sending the form to
/ Method of test: the addresses above, also submit one copy of this form within 30 days of
13a.Yield(gpm) address(es)
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised Jan.2013

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