GW1--04935_Well Construction - GW1_20240816

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 mans-cased wells)OR LINER(If a Ikable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. I ft. //5 ft 6
O7i- in. n1/C
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) I
Or6-' d���..0/� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well construction permits(i.e.County.State.Variance.etc.)
-
ft. ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO ` DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. R. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Cotttmercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation / ft- c7t, ft. LI `t, /' C//, �
Non-Water Supply Well: (J ',/
ft. IL
❑Monitoring ❑Recovery -
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicably)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage n. ft. -
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets If teary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION� TI (color,hardness,sot Wrack type,grata she,etc.)
❑Geothermal(Heating/Cooling Return) y❑Other(explain under#21 Remarks) / n• //S II. `� 2 '7 ---thi f
4.Date Well(s)Completed: 7- // -o Well ID# //5 " /01.0 n. kd_l�`'
/ ft
5a.Well Location: / '- n-r_ R, r at.5e o f I1l re/tQ'
n. n. ._.. -
Facility/Owner Name/e Facility ID#(ifapplicabk) n n
57 , , ,;% , ;1 i•,.,y
old Case. i2 jJ, ft. ft. t(; I )I')S
Physical Address,City,and Zip
d Sin 21.REMARKS ,
Ifs';::-,.. _,y,.
County Parcel Identification No.(PIN) r: `'• 1--
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifica"
(if well field,one lat/longon is sufficient)
35' ' (,l, WV N 8g S/ SS; 9D w 7-dA
Signs of Certified Well Contractor Date
6.Is(are)the well(s):)(Permanent or ❑Temporary By •gning this form.I hereby certify that the uell(s)was(were)constructed in accordance
� w" ISA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or lNo py of this record has been provided to the well owner.
If this is a repair,fill out known well construction information an explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
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
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: QV S ((t,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd different((tample-3C•200'and 2®1017) construction to the following:
10.Static water level below top of casing: 00 (fL) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+•• 1 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: La /D (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
�,- St' v/ above, also submit a copy of this form within 30 days of completion of well
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
13a.Yield(gpm) •7 Method of test "-/9 24c.For Water Supply&Injection Wells: In addition to sending the form to
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 G W-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013

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