GW1--05804_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 2.0NES
FROM TO D88CRIPTION
well Contractor Name ft, ft,
—
4137-A n. ft.
NC Well Contractor Certification Number IS OUTER CASING /b ail wells O LINER f Ikohl*
FROM TO NAMU R T !CKNRSS MATMIIAL
Clearwater Well Drilling Inc. 1t. ; << ft. t I .Is. C
Company Name Ifi.INNER CASING OR TUBING Itie•thertnat ela ted•1oe )
BoaLi- - 0 G. ')5 FROM TO DIAMETER TItICKN6Sy MATERIAL
2.Well Construction Permit#: ". 1e,^
List all applicable well canstrncilon pennies(i.e.County,State,Variance.etc.) .
ft ft,^ in.
3.Well Use(check well use): IT.SCREEN
Water Supply Well: IROM To DIAMETER 7410rslze THICKNESS MATERIAL
ClAgritalltural °Municipal/Public ft. ft' is.______
_
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. " hi'
7lndust riel/Commercial 1 . .
❑Residential Water Supply(shared) 8 GROUT
❑Irigation PROM TO MATERIAL—_ IMM.AC'tment METHOD&AMOUNT
})qq1� /����
Non-Water Supply Well: l "' oS L) ". e C� 1 1L__) i --) V i'd
❑Monitoring ❑Recur, ft. ft.
_l
Injection Well: ft. ".
DAquifer Recharge ❑Groundwater Remediation 1A SAND/GRAVEL PACK(Ifappttea*hL
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT pon
a. R.
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) OTracer 2...DRILLING LUG(attaelr Id4Htteesl sifted if fta a arry)
l aescatrl1 KA 4, Y ti!&.sst.snSM,e
(1) ft'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) i (` l
4.Date Well(s)Completed: Well ID# `Q" t"' Pi cl `
5 Wel Locatlon: �/ ,(Q°��� I.
T Yu s 1- ft. a. u•
Facility/Owner Name , /�)✓ Facility ID#(if applicable)10 (N+ lr'/�1 I✓1 " fl .:..11.. t+..I d 4..,I....
P City. ZIp
J
u l Y� l st.REMARKS 3f P ? el l
n Parcel Identification No,(PIN) l
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) �( (n i�3 22.CerUftc �o: /
a �1 C 'V ICI V N 2 . 1+I 1 u '0- W l/�...,—� <J "�1-.2 7'
Si of eettlfied Well Conownor Date
6.Is(are)the welds): ermanent or ❑Temporary
y Anew►bis form, I hereby 'that the weil(s)was(were)Cnnviructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existingwell: 0Yes or i,No
copy of this record has been provided to The well owner.
11 ibis is a repair,fill out known well construction information and explain the mature of the
repair wider#21 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 wens constructed: construction details. You may also attach additional pages if necessary.
Far multiple injection or non-water supply wells ONLY with the same corutrnction,you con
submit eine form. SUBMITTAL INSTUCTIONS
9.Total well depth below land serf/wet 1 C (ft.) 24a. 1Per All Wells: Submit this form within 30 days of completion of well
For multiple wells list a!1 depths Vet (ermmple-3®200'and 2Q101Y) construction to the following:
(.( ( (fi) Division of Water Quality,Information Processing that,IA.Static water level below top of casing:
If water level is above casing,use"+r t"n 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: " 011) 24b.For lnlection Wells: In addition to:tending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construeti.n method: rot -'' 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
I3a.Yield(gpm) 4 Method of tear 2I 9 24c,trOr Water SNDDiv&Inlection Web, 1p addition to sending the form to
the address(ea) 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 Envimnment and Natural Resources-Division of Water Quality ty Revised lam.2613

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