GW1--03182_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 (L ft.
4137-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. i ft. 57 ft. is y 5- in. Off,
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) / ,
�{ FROM TO DIAMETER THICKNESS MATERIAL
O2.Well Construction Permit#: S - , �)0Z-- /3'4 ft. ft. in.
List all applicable well construction permits(i.e.County,Stale. Variance.etc.) --
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public ft. it. to
❑Geothermol(Heating/Cooling Supply) kilesidential Water Supply(single) ft. it' in. -
❑Industrial/Commercial ID Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT/METHOD&AMOUNT
❑lnigation ( ft. t) ft. ( wan+ tr (e1 Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery -
Injection Well: It. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable
FROM TO MATERIAL. EMPLACEMENT METHOD _
DAquifer Storage and Recovery ❑Salinity Barrier rt. ft. ______,
DAquifer Test ❑Stonmwater Drainage ft. ft - -
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) / ft• ar'7 f• ,f nt'/' •f- i ✓f-
4.Date Well(s)Completed: 4-Z5 224Well 11)# 5.7 ft. . 1-7 rt, gran
r )t C �•
it. ft- ICJ <•
•
5a.Well Location' ZU� 1sU/j(j aJ5 rJ�� ft. ��r�rt. rr��� i
i /L '
(it() , ea PLC ft, ft. .
Facility/Owner Name ( 1. /ti Facility ID#(if applicable) (t ft ------4,,",., -- t. r
(V7 Jtuls N('s)- Lane ft. ft. - 2024
Physical Address,City,and Zip 21.REMARKS
t l e'h Cie!SOn •::---9 jpi,
County Parcel Identification No.(PIN) U'' .',,t')V
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificaf
(if well field,one IaUlong is sufficient)
35 a3 ` 4 N ,&? aoS(o.qi w , 4 -as-a
Signal of Certi d Well Contractor Date
6.Is(are)the well(S): rermanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or tVo copy of this record has been provided to the well owner,
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page ro 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 form. SUBMITTAL INSTUCTIONS
9.1'otal well depth below land surface: (905 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(eromple-3@200'and 20000') construction to the following:
10.Static water level below top of casing: 600 (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: (2 l7' (In.) 24b. For Injection 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: tr7-fGe)rl.i 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 2 769 9-1 63 6
13a.Yield(gpm) 7 Method of test: 1{l Cr 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 anti Natural Resources -Division of Water Quality Revised Jan.2013

W.11 Dialer Selfseinsist C. dl dion
2020 ,Rou:laers (-L
owner: &irac e t s C New Well:._-__
pe &SS- 2t)Z`-1 - ©t 4
I'hereby certify that the above referenced well WM grouted in appearance in accordance with
all County Well n _
wall Winer, �o ' D C.112 Y`��S Si
J ed' '—
Certificate*: 413"1-A 1 . 4 -D S- -a V
Construction: Grout
Total Depth; W DS TyPe:_- .4-
Casing Ty P"c Thickness: 0- 6c e ck . . -
Casing Depth: 51 :- __ --- 2-0
Diameter lQ`18
Drive Sham -
GPI* Z