GW1--05806_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD
This form can be teed for single or multiple wells For internal Use ONLY:
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I.Well Contractor Information:
Josh Plemmons 14.WATER ZON>BS
Well Contractor Name FROM -TO DE3CRiPI1ON
ft. n.
4137-A — it. ft.
NC Well Contractor Certification Number 115,OUTER.CASING(for main-cased wens oil LINER(ltapencabte)
FROM TO DIAMETER—_J THICKNESS MATERIAL
Clearwater Well Drilling Inc. 6y2
Company Name 16.INNER CASING OR TURING(ttrotibermd elosed-ioap)
2 _�h�� �J FROM DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 67(� (/ 0 " , TO
R. in List all applicable well construotMn permits(i.e.County.Saute.Verbiage.atkl
3.Well Use(check well use): R O• In.Water Supply Well: ItSCRii M
Water Suppl FROM TO DIAMETERS[10TS=ZE THICKNESS MATERIAL
`O'Municipal//Public ilk.0Agn '
OGeotbermal(Heating/Cooling Supply) �.gcsidentiai Water Supply(single) R• ft. in.
❑Industrial/Commercial /❑Residential Water Supply(shared) Pa.GROUT
Dhrigation PROM TO MATERIAL ItMrt ACaMeNi METHOD&AMOUNT
Non-Water Supply Well: / " , 0 fl' (7e/X(YAf //C /:e-f
❑Monitoring ❑Recovery R. ILinjection Well: rt. ft.
DAquifer Recharge DGroundwater Rcmediation 19,SAND/GRAVEL PACK iKapg&aNei
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMM.ACRSOINT Ramon
❑Aqu E]S
ifer Test "• R.
tormwater Drainage
❑Experimental Technology " ft.
❑Subsidence Control
❑Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(abatis additional sleets if(Weal ant)
FROM TO DESCRIrTION(cNsr,helots%satvraok We.Inds ffit.etc.)
°Geothermal(Heating/Cooling Return) DOther H.6--5 n SGt'ir'1 / `/
1 (� (explain under#21 Remarks / ,�/—!o t-
4.Date Well(s)Completed: c?� r l " ! Well ID# �� H. �� L i��/��
5a.W�Locaties: // 4 �1 t� L� u
/'"Cl /7 Ci it,
X1S - Ja."' �'64Sft• /pig•%c./Lo
Facility/Owner Name ", n r , .
Faculty[Del Of applicable)
A5 Wcuit j 4sAi4)0 n :- •.•• y
Physic ddrets,City.and Zip R, (t T
21,(REMARKS L.0 2 6 2024
County - Ir,': -"'imase Witt
Parcel Identification No.(PiN) DJ'.
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one lattlong is sufficient) 22.C sell p:
72---- _
/ si of Certified well Contractor Dote
6.Is(are)the well(s): permanent or oTemporary
\ .signing thtr form, I hereby ccrri that the a ell(s)wns(were)cumin Slanted in
accordance
7,is this a repair to an existing well: OVes or No th ISA NCAC 02C.0100 or 1 S,t NCAC 02C,0200 Wel!Corrnructhu+ dwrtr sod lhm a
If this is a repair...fill out known well cnrxatnedion Mjonnattou add ale the nature of the copy of this record bar beenin nulled to the war'/owner.
repair under#2!remarks section or on the back of this loon. 23.Site diagram or additional well details:
8.Number of wens constructed: You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply morns ONLY with the same onnstrncdnn,you can
submit one to / SUBMITTAL iNSTUCTIONS
9.Total well depth blow lased carfare: Q/LL) S (ft.) 24a_ yor Ali Welts: Submit this form within 30 days of completion of well
For multiple wells ILrt all depths ifdlhtsmu(armnpl,-J@200'and 2(a)1 a0') cotr_structton to the following:
(CZ-
({t,) Division of Water Quality,information Processing Usk,
iQ Static water level below top of casing:
>l water level is above coring.use"+' / 1617 Hail Service Center,Raleigh,NC 27699-1617
v
I I.Borehole diameter: ( cJ (h,) 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: 1^ at L( construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Progt ant
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
�7j 24c.For Water Sunvly&Injection We1sJii addition to sending the fora,to
13a.Yield(gpm) /L' Method of tech.
the
13b.Disinfection completion add above, also ress(es)
construction tot the countyh thisth form within days of
type: Amount: P department of the county
where constructed.
Form OW-t North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013

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