GW1--04942_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For internal Use ONLY:
J
I.Weil Contractor InrmationJosh Plemmons .14.WATER zoNs
PROM TO DE9CRIPTiCIN
Well Contractor Name n. ft.
4137-A .R. ft.
NC Well Contrabtor Certification Number 15;OUTER CASING(for mult•caaed.vpells)OR LINER(it kaiak)
PROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. I ft, -, fI• Lc'1 hi. f I .
Company Name t I6;INNER CASING OR TUBING(&eotherntal cloud-l6op) '
/O�3-a5q 1 lit?- _/2 J ��FROM TO J DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: Of .•+ f(Y �7(Y ft. n. is
List all applicable well construction perwitr(t.e.County,State.Variance.etc.)
ft. ft. in.
3.Well Use(check well use):
Al SCREEN
Water Supply Well: FROM TO DIAMETER tILOTa1EL I /SICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. IS. I
OGeotheta!(Heating/Cooling Supply) 1, esidential Water Supply(single) rt. ft Ia.
m
❑industrial/Commercial ❑Residential Water Supply(shared) GROUT —
❑ItTiaetion FROM TO , MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: n �L' n' CQ rn�' ��i BL k0
❑Monitoring ❑Recovery ft. n._
Injection Weil: ft. ft. -
0 Aquifer Recharge ❑Groundwater Remediation 19,SA r/GRAVEL PACK if•; IIeab(e--
❑Aquifer Storage and Recovery OSalinity Barrier PttoM MATERIAL r YMPLACEFJruYTA1ETHOD
❑Aquifer Test ❑Stonnwater Drainage _._ rt. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
21•pRILL1NC LOG(attach additional sheets If tteeeaaary)
❑Geothermal(Closed Loop) OTraoer
PROM J TO oeSCRIPTioN(cabs,haranau,indWeek 99pe,grain elm,eta•)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) t IL a3 f• SCc r"t _{.- d-i Y-4-
4,Date Well(s)Completed: L'-27 W I ID# a� n it• aY� �1 L Ot��1 C
Sa.Well Location: t��5� •l� r
ft, ft,
Facility/OwncrName Facility ID#(if applicable)
4 l--1 o f,. fi.
n. n.
Physical Address,City,and Zip
21.REMARKS -'
CAC1SGr) 4u61 F
County Parcel identification No.(PIN)
Sb.Latitude and Longitude in degrees/mtnutes/seconds or decimal degrees: Irl-j;,b ,;,4•:.^3,r.,. ,3 ;,s
(if well field,one lat/long is sufficient) 22 C o 4r..
c w 7_Y _aY
Sig Certified Well Contactor Date
6.Is(are)the wen(s):Aermanent or OTemporary
By s hog this form,I hereby cert(fy that the well(s)was(were)rnnstrueted In accordance
will ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing wen: DYes or 5i to 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 alike
repair under 021 renaai•ke section or on the hack of this form 23,Slit diagram or additional well details:
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 muhiple injection or non-water supply wells ONLY with the same construction,yap can
submit one form. SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surfacer Ed5 (ft-) 24ai. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list ail depths if different(example-3(a1200'and 2®1011) construction to the following:
'-L 10.Static water level below top of casing: es
J (ft.) Division of Water Quality,Information Proealag Unit,
If water level Is above casing,use••+' 1617 Mail Service Center.,Raleigh,NC 27699.1617
11.Borehole diameter: U , U (In,) 24b.For Infection Wells: In addition to sending the form to the address in 242
rl J{_fix �+ above, also submit a copy of this form within 30 days of'completion of well
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; 1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpsn) �� Method of test 1 4 GI 24c.J?or Water Supply&Jniection Wells; In addition to sending the form to
the address(ea) 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 dW-I North Carolina Department of Environment and Natunti Resources-Division of Water Quality
Revived Jan.2013