GW1--05809_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can he used for single or multiple wells
1.Well Contractor information:
Josh Plemmons 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4137-A ft. ft. —
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased welatLOR LINER(If applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling inc. ft. ft. In.
Company Nome _ 16..INNER CASING OR TUBING(geothermal closed-loop)
n � TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: I \I _L - C'j V�V7 3 1 ft. ft. In.
J -
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: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Liicultural n. ft. in.— —
❑Municipal/Public
fit. n, in.
iGothermal(Heating/Cooling Coolin Supply) DResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) iL GROUT
FAOM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft.
Non-Water Supply Well: _.
ft. R.
❑Monitoring ❑Recovery _
Injection Well: ft. n. —"
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicabl
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional:thects If necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTFON(color,hardness,soWtoek type,grain strr,etc.)
UGeothermal(Heating/Cooling Return) 7 ❑Other(explain under#21 Remarks) ,i'.,' ft ,7SL,, it. /-160.tG,��/ri /J
4.Date Wells)Completed:U"�� oC Well ID# ft. p. -.Cyre'4c/ �� , � rc ^
5a-yell Location: -- D D
At)/AU/1L11- D�hLe /J--621715-67---L ft. ft. 9
. a J
Facility/Owner Nara, Facility iDI/(if applicable) — — - 1
/ ft. ft. ....�,,0 4..
Physi Address,City,and Zip //VC E 2 2024
�y�j ./ i'J 21.REMARKS
..(//C_OY2t-4( j Ir:.�:T-4,i r t3'r -SAtt�-4 1.
County Parcel Identification No.(PIN) OWc63+3i!
5b.Latitude and Longitude in degrees/ininutes/seconds or decimal degrees: 22 Certitk iti
(if well field,one Iat/long is sufficient) t
Sighat re of Certified Well Contractor Date
6.Is(are)the well(s): fpermanent or ❑Temporary B signing fo . 1 hereby cet1 that the tvell(s)was(wets)canstrucre in accordance
!b 1 SA NCACThis 02rmC.0100 or I SA NCAC 02C.0200 Well Cotrstrttc riot Standards and that a
7.Is this a repair to an existing well: ❑Yes or [i<lo i 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 of the
repair under 021 remarks section or on the back of this.form. 23.Site diagram or additional well details:
C�J 5(, �1 You may use the back of this page to provide additional well site details or well
B.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple inject ion or non-water supply wells ONLY with the same construction.you can
.submit one form. SUBMITTAL INSTUCi•IONS
9.Total well depth below land surface: (fit.) 24n. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200-and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
If water level io above casing.use•'+•• 1617 Mail 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
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW- North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013