GW1--04966_Well Construction - GW1_20240816

1N61 14. 1
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I.Weil Contractor Information:
Josh Plemmons 14.WATER ZONES
PROM TO DESCRIPTION
Well Contractor Name ft. ft.
4137-A ft. ft.
NC Well Contractor Certification Number _i st OUTER CASINO(for mnkH-eaaed.welh)OR LINER(IIapplicable)
PROM 1 TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. l ft. a 1 R, .' In. p\ir
Company Name 16,INNER CASING OR TUBING(geothermal elosed-loop)
'I (� I t PROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: (\I I�)- ` .{_/ �l R. p In.
List all applicable well construction permits(i.e.Counry,State.Variance.etc.)
ft. H. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: ( PROM TO DIAMETER SLOTSiZB THICKNESS MATERIAL
❑Agricultural ❑Mtmicipal/Public ft. R' la.
D rm
Geotheal(Heating/Cooling Supply) Atesidential Water Supply(single) B. k'
❑lndustrial/Commercial DResidential Water Supply(shared) PROH"r Pr _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrrigetion
n.
Non-Water Supply Well: l� Pt. g� l�1 1 rt
❑Monitoring, DRecovery ft. n
Injection Well: — ft. ftt.~
❑Aquifer Recharge ❑Groundwater Remediation 19, • r/GRAVEL PACK If s'limbic--
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM MATERIAL r EMPLACEMENT METHOD
n. n,
0Aquifer Test ❑Stormwater Drainage —.—
❑Experimental Technology ft. ft.❑Subsidence Control
DGeothermal(Closed Loop) QTracer 2t1.DRILLING LOG(attach additional sheets if necessary)
PROM TO DESCRiP'701.i(alorrbanlaau,ralthock type,grain she,etc.)
❑Geothermal(Heating/Cooling Return) LlOther(explain under#21 Remarks) 1 n• 2' ,1 It `t, /1�1, f1� 1.ip f (j 1
4,Date Well(s)Completed: Well ID# ,�)1 n, ��;-ft, , rintri
ti ifft. ft.
5a.Well Location: — ft. n
ft. ft.
Paeility/OwarName c.0 le_ Facility ID#(if applicable) -- C.........,,,,
IWrtit h. ft, • i.)
nl i sptl D Ci n. ' D. j
MORO Address,City,and Zip t /r/iV
21.REMARKS
-an 'v1IvO 'rdc r
County Parcel Identification No,(MN) :�
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certifies on:
(if well field,(flee lat/long is sufficient)
s- ofCertified well Contractor Date
6.is(are)the well(s):4Permanent or DTemporary
signing this form, I hereby cert(f+that the well(s)was(were)consirueted in accordance
Nr ISA NCAC OW.0100 or ISA NCAC 02C.0200 Well Construction Standards and thai a
7.is ibis a repair to an existing well: ❑Yes or JNo copy of this record has been provided to the well owner.
if this is a repmh•,nil out known well construction information dud explain the nature of the
repair under#21 r•emi,ks section or on the hack gf 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple Injection or non-water supply wetly ONLY with the same araaruednn,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: %OS- (ft_) 24si. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(J200'andnn 2@100') construction to the following:L
10.Static water level below top of casing: l 0 (ft.) Division of Water Quality,information Processing Unit,
H.water level is above easing,use"I i I+- 1617 Mall Service Center,Raleigh,NC 2 76 9 9-1 61 7
U
i 1.Borehole diameter: i (24 24b.for'Mutton 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 well
�7
12,Well construction method: I lJi l/I construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) f
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm) Method of test �.(�'j 24c.For Water SuDPly&lniectlon We(iai in addition to sending the form to
I the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Dfainfeetio.i type: Amount;
where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013

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