GW1--05781_Well Construction - GW1_20240926

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
PROM t TO DESCRIPTION
Well Contractor Name ft, ft. _
4137-A R. ft,NC Well Contractor Certification Number IS.OUTER CASING(for multi-cued wens)OR LINER f a ulna
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. f ft. /.3C P/ft. 6 7 ia,
nt/l
Company Name I6.INNER CASING OR TUBING(geothermal closed-loop) pt/r
FROM TO DIAMETER THICKNESS MATERIAL.2.Well Construction Permit#:a0;3—�/t7 c(7[_ /S3O3D R, R in.
List all applicable well construction permits(.e.Cogary,State.Variance,etc.) _
ft R. In.
3.Well Use(check well use): _
17,SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. R. la —
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
---1
❑Industrial/Commercial ❑Residential Water Supply(shared) FRO1a.GROUT
M J TO MATERIAL EMPLACEMENT METHOD&AMOUNTS❑Irrigation Raj fL /t0in�/1�
Non-Water Supply Well: C i_ 1 1 m J X �(f
❑Monitoring ❑Recov�y ft. R.
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 119.SAND/GRAVEL PACK(if applicabI
sj
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
R. R.
DAquifer Test ❑Stormwater Drainage ----I
❑Experimental Technology ❑Subsidence Control It ft.
2i.DRILLING LOG(attach additional sheets If accessary)
❑Geothermal(Closed Loop) ❑Tracer
FROM , TO DESCRIPTION(tear,'melons:sellitack type,Pala site,etc.)
❑Geothermal(Heating/CoolingpReturn) DOther(explain under#2I Remarks) l ft• /Jv ft. e2 ,.-,a ,- C/,
4.Date Well(s)Completed: lJ -5-oc y Well ID# L3D ft. �`J/ fL .[�f In^, 1G! _
5a,Well Location: �`� n ��2 � /�c//)�
L�n c�� ,5��, 3/a-R, 4aS-it• a ft-J./tile
Facility/Owner Name Facility ITV(if applicable) +^ i' $ ,• .1
R. rt. L,/
/Pd/4 d1' / 1ta' 1lGt/. ft. R.
physic l Address,City,and Zip S E P 2 11 [p
/)/��y(///(' 21.REMARKS
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County Parcel Identification No.(PTN) [;+f;yam.T,,,,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certifica n:
35 -)9 r 0V.La5- N 8,2 15 t 026 .(// W h__ /(.._ - 3-9-d y
Si of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or OTemporary
signing this form, 1 hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: DYes ore copy 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 021 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: U 5 (EL) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3i200'and 244100') construction to the following:
10.Static water level below top of casing: (1 V (ft,) Division of Water Quality,information Processing Unit,
If water level is above casing,use'•++" i 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l.L/n /'(f (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: if)/ lam/) .f
�`I n l 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 Mall Service Center,Raleigh,NC 27699-1636
.
/11
13a.Yield(gpm) (&V Method of test: 14 24c,For Water SUM*&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 GW-I North Carolina Department of Environment and Natural Resources-Division of Water Qua i
tY Revised Jan.2013

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