GW1--01139_Well Construction - GW1_20240216

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons 14.WATER ZONES i ' I
FROM TO DESCRIPTION
Well Contractor Name ft, ft. It
4137-A R. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if appDcable)
FROM TO DIAMETER THICKNESS - MATERIAL
Clearwater Well Drilling Inc_ / it. /a, ft. (75 in. I /)
2.Well Construction Permit#: 202 lie
Company Name 16.INNER CASING OR TURING(geothermal dosed-loop)
DOt�/� //1 FROM TO DIAMETER THICKNESS MATERIAL
\ of ft R. 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
❑Agricultural OMunicipal/Public n ft. in.
OGeothermal(Heating/Cooling Supply) Supply(single) R' ft. in. I -
(Heatin Conlin Su 1 esidential Water Stir 1
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT l
❑hri allow OM TO MATERIAL EMPLACEMENT�METHOD&AMOUNT
g ! it. Ad fft. lfe/rl/�tw !d PL,1,6GAY Non-Water Supply Well:
❑Monitoring ❑Recovery
ft. ft. I
Injection Well: ft. ft. I
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable) l
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
R. ft.
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attachadditionaf sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soltlrock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ) / it' L SCI)a !4 i 0-f--
4.Date Well(s)Completed:1'\ -24'Well ID# r o r �� R. /yam ) r
00/ t' 6 Z rt. -P.2i 6,0
5a.Well Location:
aQ2f AZ-IL Y `.,k
Ne ifve., K ilp aln'(It> ft. ft. ' - -.. -.E_ " �ilip= 'i
Facility/Owner Name Facility ID#(if applicable) R. ft. ��� ow.°
��Win . Laut.r -1 Or, AShou tt.Q ft. rt. I ICb 1 6 2UZ4
ysieal Address,City.and ZipZiip� 21:REMARKS
1 o I . (t astir yr+++f 'te.1 r/CC^9PSiif4y?U71111
County Parcel Identification No.(PIN) 1 Ih nel f3
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifi : I tTon
(if well field,one latllong is sufficient)
"9' 45' 5`&.uIN ' Loa Iq . 4l w / -20 2�
Si use of Certified Well Contractor I Date
6.Is(are)the well(s):*ermanent or ❑Temporary
y signing this farm,(hereby cent&that the mell(s)t as(mere)constnrcted in accordance
with ISA NCAC 02C.0100 or ISA 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 ouster.
If this is a repair,fill out known well construction information and explain the nature of the
repair tender 1121 remarks section or an the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide ditional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
Far multiple injection or not-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:p ccl S- (ft.) 24a. For All Wells: Submit this!farm within 30 days of completion of well
For multiple mils list all depths if different(example-3C200'and 2@100) construction to the following:
10.Static water level below top of casing: i
(ft.) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1 1617 Mail Service Center,Raleigh,NC 27699-1617
//.9�� p 1
11.Borehole diameter: t. O (in.) 24b.For Iniection Wells: In addition to send r g the form to the address in 24a
12.Well construction method: I'V.I ( above,also submit a copy of this'form within 30 days of completion of well
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: �i/ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) D Method of test:
r 24c.For Water Supply&Iniection 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 tot the county 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

•
Wall Dear Self•Ilmut Cionkation
Ovvner;S Gre-New Welk
Repair
Perot Zb - 00
thereby certify fhat the above zeterenced wel was grouted in appearance, a a • a-NM&
all mum Wen roles.
Welt Wier );ft aOltVi 005 Signed: i--------
C,erdficate#: 446/ - Dato I
construct:tam Gotat
Totid Deptit eirm-etJ
"•.1 X.
Casing Tipe: pve.
Caving Depth: M Depth; g9r)
Diameter: 0 17
Height__
Drive Shoe:
GPM, r9i0