GW1--00672_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells I Forlotemal Use ONLY:
1.Well Contractor Information: It iI
Josh Plemmons 14.WATER2 � I
QNEs '
FROM TO DESCRtPTiON I _
Well Contractor Name R. ft,
4137-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casedswells)OR LINER(if ap llcabte) • -
FROM TO DIAMETER 1 THICKNESS I' 045 id to 78fil. i MATERIAL
Clearwater Well Drilling Inc. /
Company Name 16.INNER CASING OR TUBING(geothermal dosed-coop) p
2.Well Construction Permit!#: f5S -° 1( 3- //0f� FROM TO DIAMETER THICKNESS MATERIAL •
ft ft. in.
List all applicable well construction permits(i.e.Coanry,State.Parlance,etc.) I
fL ft. 1 in. I
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER' SLOTSIZE THICKNESS MATERIAL
DAgricultural °MunicipallPublic ft. ft In,
°Geothermal(Heating/Cooling Supply) XRResidential Water Supply(single) ft. ft• In•
Olndustrial/Commercial °Residential Water Supply(shared) 1S.GROUT - i
°irrigation FROM TO MATERIAL EMPIACEMENTAfEf/nOD&wMOITNT
Non-Water Supply Well: / ft. a0 ft' (�-'/ ! r I ni ,l,€
°Monitoring ❑Recovery n. ft. I '0 i Y
Injection Well: ft. ft. I
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) I -
°Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
- °Aquifer Test OStarmwater Drainage f R� 1.
°Experimental Technology °Subsidence Control ft. ft.
°Geothermal(Closed Loop) °Tracer 20.DRiLLING LOG(attach addllioual Sheets If ndcrosary).
FROM TO DESCRIPTION(color.hardness,solUreck type.Erma size.dal
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) / n• q�, ft- ()ia_p7a 4.Date Well(s)Completed: Well ID# /Y t, j �14 i ; '-1/i'i1..
viii .
fp'e/tl Location: , j / i I
(t d F -i(y, Pvr c l_(��. 7 2 ft. �Usft- !!i t �-. _
Facility/Owner Name Facility ID#(if applicable)_ R. I ' �.5 a yl a J .,.,5 3
ft. ft. I -- •• -, i,,., r
ell (d d, ae soi 1 J Lc .. A
Physical Address,City,and Zi NC I J A N 4 2UZ4
21.REMARKS
He )die c.5-on 610S-04s"4nl Fa t �. ._, 3=.; :.„ •:;:0 tit,
CountyNPD:C••wr,t_
Parcel Identification No.(PIN)
5b.Latitude and Longitude hi degrees/minutes/seconds or decimal degrees: 22.Certillc
(if
if2 well��field,one latilang is sufficient)
35
.</Q �J�. N (S3i 550 ` 73. ELc w 1 - -A ct
Si of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or °Temporary
By igning this farm.I hereby certify that th'e well(s)tihos(were)constructed in accordance
zth 15A NCAC 02C.0100 or ISA NCAC 02C.0280 iI'II Construction Standards and that a
7.is this a repair to an existing well: °Yes or t copy of this record has beer provided to the well owner.
If this is a repair•fill out known well construction Information ehlain the nature of the
repair under 1111 remarks section or on the back of thisforn,. 23.Site diagram or additional well details:
You may use the back of this page to provide a ditional well site details or well
8.Number of wells constructed: construction details. You may also attach additi al pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: S 0 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi erent(example-3®200'and 2®100' construction to the following:
10.Static water level below top of casing: 2-0 (g,) i
Division of Water Quality,informa'on Processing Unit,
If wester level is above casing.use"+•' 1617 Mail Service Center,Ralei ,NC 27699-1617
11.Borehole diameter: .101 ' c 0 (in.) 24b.For Iniection Wells: In addition to sendi g the form to the address in 24a
r�� � above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1 construction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground I jection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,lialeig NC 27699-1636
13a.Yield(gpm) Method of test 24c.For Water Supply&injection Wells In aHdition to sending the form to
the address(es) above, also submit one'cripy of this form within 30 days,of
completion of well construction to the county ealth department of the county
13b.Disinfection type: Amount
where constructed.
Form OW--1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

W.I1 Winer Sali4knat Cotilikatkin
Owaer:-Vk JtV- New Well:
AdtherEk0 &PAM
Penst OSS (-7DM - DO
hank oat*that the above reknoced well was grouted in appearance In •with
all Canty NWIE roles.
Well DrillerJRAM V\Lroc S Signed: I/
Certificate 4 \ DADow • I
CATOStrUCtilM: GIVNLIt
Total Depth:
Tyttm_=Ceryt-
Canir1iPe: ON)e- Titidatesr. TV Le Cl
Casing Depth: Ct
•
Diameter, VP% 1
Heigft
Drive Shoe:
OPM: 3