GW1--03180_Well Construction - GW1_20240524

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
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4137-A it. ft.
NC Well ContrnctorCertitication Number 15.OUTER CASING(for multi-cased wells/OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 R. 5) ft. (9 u" in.
NC
Company Name 16.INNER CASING OR TUBING(geolhcrmal closed-loop)
C< r}}rr l� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: COS-n(l.i_ r �;I �1 n. ft. in.
List all applicable well construction permits(i.e.County,State.Variance.etc.) it. ft In _
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROSt TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. In.
❑Agricultural DMunicipal/Public
❑Geothermal(Heating/Cooling Supply) �tesidential Water Supply(single) H. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Ill.GROUT
FROM TO MATES L) LA �M EMPLACEMENT/ MET &AMOUNT
❑Irrigation i it. i it. ( /}f 1 1 l J r C f 1 cTD
Non-Water Supply Well: ft. V ft.
OMonitoring ❑Recovery
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable)
FROM TO MATERIAL_ EMPLACEMENT METHOD
DAquifer Storage and Recovery ❑Salinity Barrier n. ft. _
DAquifer Test ❑Stormwater Drainage ft. tt
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,
ass,solUrock hpc,gain size,etc.)
❑Geothermal(Heating/Cooling Return)
7(� ❑Other(explain under#21 Remarks) 1 ft. �1 ft. k f )/Z `i-/ (l V-1--
4.Date Well(s)Completed: ` e ) Well ID# j EL
C•l/� tt ��1 (�1, l�
54 f- 5y R. C e, ►'l �
5a.Well Location: �74 fL Ctli J `rt• c -(,111 e
7_n.zu ►? �lotus Ll C ft. ft.
Facility/Owner Name Facility ID#(if applicable) -- '. ' _-. . ' -::-
ft.ft. ft.
l 1 fut--1 i I2j ft. ft. 'L\Y 2 z 2024
Physical Address,City,and Zip
21.REMARKS
ke lC IXSOV) `,,.-*-
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
?.5' S• 15 c1(0N 1- ca .0Y W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By.signing this form.I hereby certifJ'that the nell(s)nag(here)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or �o copy of this record has been provided to the hell owner.
If this is a repair,fill out known well construction information an plain the nature of the
repair under#21 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 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 one farm. SUBMITTAL INSTUCTIONS
9.Total weft depth below land sur•tace: LP II u' r (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: L) 0 (ft.) 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: LC'' Q (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
11 above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: f N( ,,)( l j construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) f
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpm) 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 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

•
Well Driller Self•iirOut Cortif*rpon
LC
2 7-0 i6u�lG1,e_�"S �-
(3vvntr': New
I hereby certifythat the above referenced well was grouted in amen's=inaccordocewith
oil County Well rules_
well Dxflter .1csh POTIDERS3`
ConstIlid10n: Grout:
Toles Arch; .o US—. Ty C ernel.-'r
Casing : p\i Thickness: i
Casing Depth: 5-0 Depth:
�¢`l
Height—
Drive Shoe:
GPM: --.-.