GW1--05810_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD
This form can be used for single or multiple welts for Internal Use ONLY:
I.Well Contractor Information:
Josh Plemmons 14.WATER ZONES
Well Contractor Name FROM TOI DESCRIPTION
rd.
4137-A a
A. ft.
IS.,OUTER CASING(for maltleased wells,)OR LINER OfaOp lrabte)
NC Well Contractor Certification NumberFROM I TO I
Clearwater Well Drilling Inc. ft. DIAMETER � TN(CKNggg MATERIAL
In.
Company Name l� 16.INNER CASING OR TUBING(gsonatina!eleaed-loop)
1
2.Well Construction Permit#: Y V�.� DI D0 1�]3 RROM TO DIAMETER THICKNESS MATERIAL
Use all applicable well constructionff• p. In.
permits(i.e.County,State.Va iance.eta) --
3.Well Use(check well use): ft ft. tam
Water Supply Well: r 17.SCREEN
al!OM TO DIAMETER SLDTSMZE THiCKNESS ' MATERIAL
OAgricultural O Municipal/Pub lic ft, ft. in.
licCreothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft• In.
❑Industrial/Commercial ❑Residential Water Supply(shared) I 11S,GROUT
Qlrrigation FROM TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. R.
❑Monitoring ORecovery ft. ft.
Injection Well: ft, ft. --
°Aquifer Recharge °Groundwater Remedlation 719,SAND/GRAVEL PACK(if sppileaN [
DAquifer Storage and Recovery ❑Selinily Barrier short TO MATERIAL _ _____, EMPLACEMENT METHOD
❑Aquifer Test ft. a.
DStonnwater Drainage
❑Experimental Technology 0 Subsidence Control ft ft.
❑Creothermai(Closed Loop) OTracer 20.DRILLING LOG(attack eddstioaal ftdy if necessary)
FROM re DESCRIPTIONiNar,Imams,aolYmek tyae,teal aloe,eta)
°Geothermal(Heating/Cooling Rotu)m) l QOther(explain under#21 Remarks) ft. ft.
4,Date Weil(s)Completed:� 0(a -0(7 Well iD# R' D�D0' roleznrwlla.Wall Locadon: ( Q±rie� JDI" R. �1.�J�' (SO ifri
i ICt RaiYli rez, ft• lit,
ib/Owaer Name
ame
Facility tD#(if applicable) ft' R __
W I I rr D'j k G T .• n. n
.' -P I Address,City.and Zip 1'n ft. ft _. . a:. t
� > A8hL `"` 21.REMARKS I'�
County •
Parcel Identification No.(PIN) �� ���"
Sb.f Latitude and Longitude in degrees/minutes/seconds or decimal degrees: : ?arr.- `- 1 a
ell field,one lati10 g is sufficient) 1 22.Certlle"' 'n: �7YT.a$(�y «—itx
a' . 3. i U2 N cka 37 "LQ. a Ct w / eo( �' s �
6.Is(are)the well a: S. ore ofCertified Well Cnntraoter Date
(1 ermanent or []Temporary
y signing this fink I hereby cent&that the neel/(s)weal(were)coac ,ed in accordance
7.Is this a repair to an existing well: ❑Vas or ( to with ISA NCAC 02C.0100 or 154 NCiC 02C.0200 WW1 Construction Standards and that a
If Mk is a repair,fill out known well construction d/\ copy offto been provided to the wed owner.
nee.
repair under 1121 remarks section or an the hack thi m. on erplatn the r:oture nfrtre
f J 23.31te diagram or addltbnai well details':
8.Number of wells constructed: 3 BCD You may use the back of this page to provide additional well site details or well
i
l tipe njecrlwr or non wotar construction details. You may also attach additional pages if necessary.
For multiple
submit t af nn supply welts ONLY with the sense consonants,you can
SUBMITTAL iNSTUCTIONS
9.Total well depth below land surface: err.) 24a.For Alf Wefts: Submit this form within 30 days of
For multiple wells Ito all depths if*Aran,(eronrples 3@]00•and 2@1� Y completion of welt
construction to the following:
10.Static water level below top of casing: (fL) Division of Water Quality,Information Processing Unit,
if water level is above easing,use"+" 1617 Mall Service Center,Raleig
h,NC 27699-1617
11.Borehole diameter. (in.) 24b.For!Median Wells: in addition to sending the form to the address in 244
12.Well colhBtructian method: above, also submit a copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct construction to the following:
push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
i636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24e.For Water SanMv&Inlectlon We ntiln addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection : Amount: completion of well construction to the courtly health department of the county
where constructed.
Form GW-I
North Camlitts Department of Environment and Natural Resources-Division of Water Quality
Revised Ian.2013