GW1--06248_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD !For internal Use ONLY:
This form can be used far single or multiple wells I
1.Well Contractor Information:
Josh Plemmons 14.WATER ZONES + 1
FROM TO DESCRIPTION ' I
Well ContractorName R. rt. I '
4137-A ft. ft. -
NC Well Contractor Certification Number 15:OUTER CASING(tor multi-cased walla)OR LINER(if ap,llcable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling inc. R. R. In.
Company Name _ 16:INNER CASING OR TUBING_(geothermal closed•loop)
h// -•0/60 743(0 FROM TO DIAMETER THICKNESS MATERIAL •
IWell Construction Permit#: /'. v ft. R. M. . I '
List all applicable well construction permits(I.e.County.State.Variance.etc.) ft. ft. hi. •
3.Well Use(check well use): 17:SCREEN i
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL -
❑Agricultural ❑Municipal/Public ft. ft. in. I
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R ft. in. I
❑Industrial/Commercial ❑Residential Water Supply(shared) iS. I
FROMGROUT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
°Irrigation ft. R. I
Non-Water Supply Well: -
OMonitoring ❑Recovery It. ft.
Injection Well: n. ft. I
❑Aquifer Recharge O Groundwater Remediation IS.SAND/GRAVEL PACK(If applicable) I
FROM TO MATERIAL ; EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier
it. ft.
❑Aquifer Test DStormwater Drainage
R. ft.
❑Experimental Technology ❑Subsidence Control -
20:DRILLING LOG(attach additional sheets ifnecessary) •
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D n. ,15D ft. aee27e-h€r/y2 D
R. R. fit ()J)eL c''
4.Date Well(s)Completed: -/`(�Ptah ID#
ft. ft.Sa.W,ccll�lLoccation:L �1� r• © ft. SOP n• qe.f.D,/A f h4I1
492)24-
FacFacili /Owner Name Facility ID#(if applicable) — ft. ft.
I
011 Tom, Apia,- Tom. i1shevile ft. ft. I
Physic?/JOJTh)t
I Address,City, d Zip
2A.REMARKS
9702/-73-00!3 '' ,I
,..,,, , ,.5, it ,r'. ".,�
County Parcel Identification No.(PiN)
OCT. 9 1 cut
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certific i n•
(if well field,one latflong is sufficient) �j // .
'3Cf r f g:Y t7 N Yeg e 3l0 q3.b 770 W ,- - /,' _—:,a..i[); Cti, },-t--'J`�q—o(0 a7 Y
Si re of Certified Well Contractor I Date
6.Is(are)the well(s): I erntanent or ❑Temporary signing this form,I hereby curdy that the well(s)was(were)constructed in accordance
` with 15A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or $lo copy of this record has been provided to the well owner
if this is a repair.fill ant known well construction information and explain the nature of the
repair under#2!remarks section or on the back of this loom d,) 6`� 23.Site diagram or additional well details:
��1V You may use the back of this page to'provide additional well site details or well
R.Number of wells constructed: 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 fonn. SUBMITTAL INSTUCTIONS
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((different(example-3@200'and 2(01001 construction to the following:
10.Static water level below top of casing: (O,) Division of Water Quality,information Processing Unit,
If water level is above casing.use"+•• 1617 Mail Service Center,Raleigh;NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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&Infection 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013