GW1--05783_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells 1 for Internal Use ONLY:
I.Well Contractor information:
Josh Plemmons 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. fe J
4137-A m. ft.
NC Well Contractor Ceni Nation Number IS,OUTER CASING(for multi-cased wells)OR LINER(lisp kable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft. i in.
Company Name 1G INNER CASING OR TIMING(geothermal dosed-loop)
FR
ff wT f�/ p �� OM TO DIAMETER THICKNESS MATERIAL
Z.Well Construction Permit#: V - (� ; ft, ft. in.
List all applicable well construction permits(i.e.County,State,Variance,etc.) .—
ft. ft. In.
3.Well Use(check well use):
17,SCREEN —
Water Supply Well: /ROM TO DIAMETER SCOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public ft, ft in.
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
,
❑Industrial/Commercial 0 Residential Water Supply(shared) FIS.RO GRM OUT
TO MATERIAL EMPLACEMENT METHOD et AMOUNT
❑Irrigation ft. It.
Non-Water Supply Well: —' ---4
❑Monitoring ❑Recove ry ft. II.
Injection Well: ft. ft. -- —
❑Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applleabla.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL— EMPLACEMENT METHOD
DAquifer Test ft. ft.
❑Stormwater Drainage —
❑Experimental Technolo ft. It,
gY ❑Subsidence Control
❑Geothemtal(Closed Loop) ❑Tracer 211 DRILLING LOG(attach additionalsheets If necessary)
FROM TO DESCRIPTION{color Msrdscaa,seWraek tP)t grain abet etc.)
DGeothermal(Heating/Cooling RIe-tuurn) ' ❑Other(explain under#2!Remarics) 0 ft• 3�"- Qr 11) t -1-htj-/Y�
4.Date Wells)Completed:ff` /-,^�r/Well ID# t �f-1 f /�!"� a.
al. ft spa
u 5A Well Location:
C.V�{t I Q � f y 64 /tin er ft. ft.
ft. ft. _
Foci� �'O�Nattre Fadtlity UN(if applicable) "` .., m+1•
4' i 7 ft. ft. SEP
s,...
Physical Address,City,and Zip S E P 2 O
`T e, s n 21.REMARKS
— J i�24
Con//nry((�� ��SU Irr-—..r..:'r,-. tPrr.. ,
Parcel identification No.(PiN) ihA -Al
Sb.Latitude and de in de Cw.s` '� 4�"
Longttu green/minutea/seconda or deciroal degrees:
(if well field,one lat/long is sufficient) 22.Cerdt3c ,
.35- '�,-/S- -,3o91,fi ff3 i O lq_ dl�� W —. CY-9-d-
Si of Certified Well Contractor Date
6.Is(are)the walks): *armament or ❑Temporary
.signing this fora,1 hereby certify that the mil(s)was(were)constructed in accordance
ith 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1io
copy of this r eca.d has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or an the back of this from. 23.Site diagram or additional well details:
rl& 3 5 P' You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: DC construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you
submit nne form. can
SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if different(example-3@200'and 2@Joo) 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 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection 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
12.Well construction method: 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) Method of test: 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
tab.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form CAST-I North Carolina Department of Environment and Natural Resources-Division of Water Quality
Revised Jan.2013