GW1--04107_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:
NRS
Josh Plemmons -i;o A TRR o DESCRIPTION
Well Contractor Name It ft.
—4137-A •ft. It.
15.OUTER CASING(for multi.enust Fell)OR LLNBR Of npplka$e)
NC Well Contractor Certification Number
FROM TO 1 DIAMETER THICKNESSI MATERIAL
Clearwater Well Drilling Inc. rt, ft. I( in,
Company Name I6,'INNER'CASING OR TUBING*ethernet elosed-loop)
}_ _ ( ;'� 1FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: \'\I_L- C)(�)f) [E LS/ n• n. In. — -
DV all applicable well construction permits(1.e,County,State.Variance_etc.) fL ft. in,
a`
3.Well Use(check well use): 117.SCR12EN I
PROM TO DIAMETER SLOTS17i THICKNESS MATERIAL ,
Water Supply Well: n. ft. in. •
❑Agricultural ❑MunicipalfPubiic _
n. ft. in.
pti otherInai(Heating/Cooling Supply) 0 Residential Water Supply(single)
/❑lndustrial/Commerciai ❑Residential Water Supply(shared) 1111'GROUT
EROM TO MATERIAL _ BMN ACEMENT METHOD&AMOUNT
❑Irrigation ft. n.
Non-Water Supply Well: II. ft.
❑Monitoring ❑Recovery —• `
Injection Well: rt. n,
❑Aquifer Recharge ❑Groundwater Remediation 19.SA 1/GRAVRLPACK if a L.,li able _
vwoee MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier — f, rt.
❑Aquifer Test ❑Stormwater Drainage n ft.
❑Experimental Technology ❑Subsidence Control 25.DRILLING LAG(attach additional moat if u.esasary)
OGeothermal(Closed Loop) ❑Tracer FROM r TO ,toesatii TIOP(men,Ima s%/Ai .ca ode asg elm)
t❑Geothermal(HeatinglCooling Return) ❑other(explain under#21 Remarks) L R' .3(,�ff. t �"
'^ l '( n. rt. m � SC�.I
4,Date Well(s)Completed: to_1 i/o aq.Well ID# ft. R.
5a.Well Location: n• ft.
Ca e_ Wo -Cly_r91 Sival-+ "Racy ) - n, ft.
PacilitylOwrarName Facility iDq(if applicable) ft. ft 1--F'EVED
. ` _n ntJ
ical Address,City,and Zip SCA-\ /1\\-C_ , -C U.REMARKS ill illti
Ion
County Parcel Identification No.(PIN) ri' it ?a`t•,es.4..=U.
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22
(ifwell field,one fet1tong is sufficient) • J„_f/„ . ~J L/
5' . 3'3.1D N ?a 31 7 1-►. .CU W _ (�/ !C!/ /
s'.., ofCenifed Well Contractor Date
6.is(are)the well(s): *ermanent or ❑Temporary By.gning this form,I hereby certjfy that the well(?)was(were)conarruered in accordance
ib 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or , No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the Site diagram or additional well details
repair ander#21 remarks section or on the hack of this form 23.
36D You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple iryectlor or not-water supply wells ONLY with the terse coestnietlem.you can SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells iBt all depths if different(example-3c 200'and 2@l001 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 Iniectien 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,c.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
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells; Ip addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: Amount: completion of well construction to the county health department of the county
h P where.constructed,
Form 0W-I North Carolinra Department of Environment and Natural Resources-Division of Water Quaiiry Revised Jan.2013