GW1--04863_Well Construction - GW1_20230728

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: i
Josh Plemmons 14.WATER ZONES ; I
FROM TO DESCRIPTION I
Well Contractor Name R. ft.
4137-A ft. R.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if op Heable)
FROM TO DIAMETER THICKNESS 1 MAT L
Clearwater Well Drilling Inc. I ft' 15 ft. n(r�in. I phi
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
OSS "72 O��}� FROM TO DIAMETER THICKNESS MATERIAL
2.We14Construction Permit#: 2-0/�J p{ In.
List all applicable well construction permits(i.e County.State.Variance,etc.)
ft. ft. in.
3.Well Use(check well use): -17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
R. ft in.
°Agricultural OMunicipal/Public
❑Geothermal(Heating/Cooling Supply) I Residential Water Supply(single) ft. in.
❑IndustrialCommercial ❑Residential Water Supply(shared) 18.GROUT I
FROM TO (lMAATEyRIIA�L(�y, EMPLACEMENTEM � n' METHOD&AMOUNT
❑Irrigation ` ft. 7D R' U;111X 4 11 Li'U-0
Non-Water Supply Well:
❑Monitoring °Recovery ft. ft. I
Injection Well: ft. ft. I
°Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable) i
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
it. ft. I
❑Aquifer Test ❑Stormwater Drainage R.❑Experimental Technology OSubsidence Control ft. I _
20.DRILLING LOG(attach additional sheets If necessary)
°Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sentrotype,Mtnsize,eta)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (1 ft. ft. c l ' ck
11��-
N
�
4.Date Well(s)Completed: Well ID# ' R. ' ft. M/`JI�I )
5a.Well Lo on:
oprow-kr,
c ) , P Pil )t , -hens It a • ft. ft I
Neill /Owner Name 1 Facility iDS(if applicable) R H. ��
Z51 cif brit Les lanl Dr. ft. It. a`�' 4 � -
Physical Address,City,and Zip 21.REMARKS i JUL2 a?n 2
.A onJ L
County Parcel Identification No.(PIN) 1{t✓1vr,Y.a r—i Pfc r .1 Ufa
CW�rl" -- -�C
..,.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: y
22.Certiti t i rp:
(if well field,one tat/long is sufficient)
-vial (99 ,raN ' 43' 8Dtg5 W 7-6?a13
Si: .. true of Certified Well Contractor Date
6.Is(are)the well(s):,Permanent or °Temporary By signing this form.I hereby term that the wells)was(were)constructed in accordance
with ISA NCAC 02C-0(00 or ISA NCAC 02C.0200 pH 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 owmer.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 112(remarks section or on the back ofthis 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 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 onefortm ` t I _ SUBMITTAL INSTUCTIONS
`I 9.Total well depth below land surface: -`fT (it) 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®100') construction to the following:
10.Static water level below top of casing: (ft,) Division of Water Quality,Information Processing Unit,
((water level is above casing.use"+" I 1617 Mail Service Center,Rale gh,NC 27699-1617
I1.Borehole diameter: `i2 1% (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
(�...(_/y above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1�)1 V� 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,Rale,gh,NC 27699-1636
1:4______
13a.Yield(gpm) 1.V Method of test: 24c.For Water Supply&Injection 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 count) health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

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Perm* CSS - 21MS 2_3
Ibefeby certrytbat the abovereferenced weAtns glowed;n appearance inaox with
all CountyWell role&
wen Dow Azsim 'Planrmns //,--
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Total Depth: LV4 'TYPe:.... _
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Casing Depth: r.61---
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GPM: IA)