GW1--06243_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells i J
1.Well Contractor Information:
Josh Plemmons 144,WATER YANKS
FROM TO DESCRIPTION , I
Well Contractor Name ft. ft
4137-A ft. ft. -
NC Well Contractor Certification Number IS OUTER CASING(for mold-cased wells)OR LINER(If applicable)
FROM TO DIAMETER , THICKNESS MATERIAL
Clearwater Well Drilling Inc. ft. ft. in,
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WE- DI ��� FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: -]h 1��11 Jl rL ft. in.
List all applicable well construction permits(i.e.County,State.Variance,etc.) ft. IL in.
3.Well Use(check well use): 17.'SCREEN I
Water Supply Well: FROM TO DIAMETER SLOTSiZEI THICKNESS MATERIAL
�❑� ❑Agricultural Municipal/Public
f. ft, in.
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) rt. R' hi.
❑industrial/Commeroial• ❑Residential Water Supply(shared) GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft. I
Non-Water Supply Well: ,
['Monitoring ['Recoveryft.
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable). . I
FROM TO MATERIAL I EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier ft. ft.
DAquifer Test DStormwater Drainage
ft. ft. I
['Experimental Technology OSubsidence Control 20.DRILLING LOG(attach additional sheets If necessary) -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,bar'dness,sail/reek type.grain she,ete.)
❑Geothermal(Heating/Cooling Return) (❑Other(explain under#21 Remarks) D f. goo R• 9 eQ• , 4J �1�{
4.Date Well(s)Completed: ( "/c 7$ ell iD# ft, rt. �l �; ��
ft, ft. �C v
5a.Well Location:
/ ft. fr.
//ei l/ / A lich / (lynx)s ft. ft. i,. ..
Facility/Owner Name FaclilityiD#(if applicable) ft. ft. ` -:_<,l ;a..._ t_""j -
ll9 / ,iiio; L /1 het i7 rt. ��1.:1 S I 2024
Phys al Address,City,and Zip / 211.REMARKS I,)(vm Q7,2/41/7716,7,0DO0t'S r:. , r
%�. ..tt.
County Parcel Identification No.(PIN) I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Corrine ' .
(if well field,one let/long is sufficient) .
35'3Q' lnr 33 N M . 37 7021 W ..� / _ 9' 104g
7fCouified
re Well Contractor I Date
6.Is(are)the well(s): permanent or ❑Temporary ing this fort,Ihereby certt&that the well(s)was(were)constructed in accordance
A NCAC 02C.0100 or iSA NCAC 02C.0200 we 1 Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or No copy of this record has been provided to the'well owner:
if this is a repair,fill out known well construction lnformailon an explain the nature of the
repair under#21 remarks section or on the back of this form. • 23.Site diagram or additional well details:
0_ You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: t2 a -T construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form, SUBMITTAL INSTUCFIONS
9.Total well depth below land surface: (ft,) 24a. For All Wells: Submit this form within(30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2@l00' construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Quality,Informs on Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigb,NC 27699-1617
11.Borehole diameter: (in.) 24b.For injection Wells: In addition to sending the form to the address in 24a
yr l�1/� above, also submit a copy of this form within 0 days of completion of well
12.Well construction method: 1 D 1(I construction to the following:
(i.e.auger,totaty,cable,direct push,etc.) 1
Division of Water Quality,Underground I jection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleig NC 27699-1636
13a.Yield(gym) Method of test: 24c.For Water Supply&Infection Wells: Tn addition to sending the form to
the address(es) above, also submit one copy ofl this form within 30 days of
13b.Disinfection type: Amounft completion of well construction to the:county h Ith department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013