GW1--06245_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can he used for single or multiple wells
1.Well Contractor information: I
Josh Plemmons 14.WATER ZONES
FROM TO DESCRIPTION I
Well Contractor Name ft. ft. I '
4137-A It. IL
NC Well Contractor Certification Number IS OUTER CASING(for multi-cased wells)OR LINER(If app feeble)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. It IL In.
Company Name 16.INNER CASING OR TUBING(geothermal closi d-loop)
l�, t FROM TO DIAMETER TIHCKNPSS MATERIAL
2,Well Construction Permit#: V V_l "©� � �4 It. R. in.
List all applicable well construction permits(i.e.County,State.Variance.etc.) R. R. in.
3.Well Use(check well use): 11 SCREEN I
Water Supply Well: FROM TO DIAMETER SLOTSIZEI THICKNESS MATERIAL
R. ft. in.
❑Agricultural . ❑Municipal/Pubiic
Geothermal(Heating/Cooling Supply) P sidential Water Supply(single) R ft. In.
❑Industrial/Commercial. ❑Residential Water Supply(shared) 1tt:GROUT I
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. R. I
Non-Water Supply Well: R. O.
❑Monitoring ❑Recovery
Injection Well: H. /l,
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK(If applicable).
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
ft. ft
❑Aquifer Test OStormwater Drainage ft. ft. 1I
❑Experimental Technology ❑Subsidence Control 20;DRILLiNG LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,haddncss,solVrock type,wain attc,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 IL c ? 7 IL geo 1.-hi ri*id I 9ivuf
ft.
4.Date Well(s)Completed: Well iD# ft. ft. (ram '
5a.Well Location: )5 Kasela-K
ft. ft. I
kJbr"1-h l-c ilk Vm•k -GS i t CI ft. ft. 1 °' ._
Facility/Owner Name Facility lUll(if applicable) 1k. ,'; `
IL It. - k ;L.,, L.,, 'i ','-
.a.
..ma �1iIMO T) urn\I Re . Fr% - ft. R. I OCT 9,, 1 7024 ..
_
Phsteal Adddrress,City,amend Zip© r V CZ d CL I.l 21.REMARKS I}I
fCJSAA Itnl J ,!/tom tt'.I'�..,. � r�. .e.':':!irsX.
i. - i i
County Parcel identification No.(PiN) O'aai.a'i:i t0
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certi call :
(if well field,one let/long is sufficient)
35' 531 ' ICI,55 N 3at 31' y-. l3 w J / q-2& -.?v
Si a of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By.• Mg this form.I hereby certl'that the well(s)was(were)constructed in accordance
w't 15A NCAC 02C.0100 or ISA NCAC 02C.0200 We)l Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or VNo copy of this record has been provided to the well owner.
((this is a repair;fill out known well construction it formation an explain the nature ofthe
repair under#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 ad itional well site details or well
8.Number of wells constructed: 3 c -P4-, construction details. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells O Y ^l D1 with the same construction.you can
submit onefonn, SUBMITTAL iNSTUCI'IONS
9.Total well depth below land surface: (IL) 24a. For AU Wells: Submit this form within 0 days of completion of well
For multiple wells list all depths ifdlrent(example-3 200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
limier level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For iniection 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: j(i.e.auger,mtary,cable,direct push,eta) Division of Water Quality,Underground IJ'eetion 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&Infection Wells: in addition to sending the form to
the address(es) above, also submit one,copy oft 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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