GW1--03184_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.WATERZONES
FROM TO DESCRIPTION
ft. ft.
Well Contractor Name
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_ l ft. 1 <3 ft. in. Steel
Company Name C 16.INNER CASING OR TUBING(geothermal closed-loop)
�/ - FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:(.5E '202 T '3! ft. ft. 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
ft. ft. in.
❑Agricultural ❑Municipal/Public _
❑Geothermal(Heating/Cooling Supply) 14Residential Water Supply(single) ft. ft. in. _
0 Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
FR0111 TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑irrigation ft. ft. (.nyy�,
Non-Water Supply Well: ( f') 1C t'e,I� m t {�E�,
❑Monitoring ❑Recovery it. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable -
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier rt. ft - -
❑Aquifer Test ❑Stormwater Drainage it. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiVroak type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑other(explain under 421 Remarks) l ft- j i 5. ft, C 11\ t +c1 r+-
4.Date Well(s)Completed: Lk.-- 2-)4 Well ID# 1 a n 3 fL �()rani
( -1-e
Sa.Well Location: ,--3 -to rt. 3'47 ft. l rtii ce
(('�� � � )4� ft. '�n earl ie
Z�� 1`�)► ��a Le, ft. ft.
Facility/Owner Name1 Lc 11 " Facility IDO(if applicable) ft. ft.0 ‘l il'T\f'. , (Ill ft. ft. . - * r f...1'
Physical Address,City,and Zip 21.REMARKS LAY 2' 2024
County Parcel Identification No.(PIN) 1Tf2il'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: "`` y*'
(if well field,one lat/long is sufficient) 22.Certif anon:
35' ' 1a,1(V N VA' 34 ' cl--1. Lri W r (1-A5-a y-
Signat of ertified Well C c or Date
6.Is(are)the well(s):`i 'ermanent or OTemporary By going this form.1 hereby certify that the well(s)was(were)constructed in accordance
wi 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Po o c v 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 1(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 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 well depth below land surface: 4C)5 (it.) form 24a. For All Wells: Submit this within 30 days of completion of well
For multiple wells list all depths if different([e-mail] 2@l001 construction to the following:
10.Static water level below top of casing: LL' (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: \ Q (in.) 24b.For lniection 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: 1Di-a.ry 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 27699-1636
))
13a.Yield(gpm) :71 Method of test: C,ic. 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

Wail Dialer SalifieroutCatiifka tion
u:Idc c-s cs rc New.
I hereby certify that the above referenced well wrc Scouted in ate to aaxxxlance with
all County Welt rules.
then Dam - c th f.) nrNIIND(1$ S` •
Certificate*: - Date `.A -P`k.,.
Ccnrys'tr on: Grout
Total Depth; , y e:)5 `hype: Cer 1+
Type:Casing S Thickness: SYNOLeri
Casing t 1 S _ :_ ,90 .
Vokightfibidc: ,
Drive Shoe: .
GPM:_.