GW1--03674_Well Construction - GW1_20240618

WELL CONSTRUCTION RECORD For lame Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: —
Josh14.WATER ZONES
Plemmons
TO DESCRIPTION
Well Contractor Name ft. ft.
•
4137-A ft. n.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS __1 MATERIAL
Clearwater Well Drilling Inc. 1 it. -L44 ft. L,1 L in. 1%\J'(.
Company Name +n ce n /� j(�f 16.INNER CASING OR TUBING(geothermal dosed-loop) r
2.Well Construction Permit It: l��J QCO�(�' l�1 2(r�� FROM O TO R DIAMETER In THICKNESS MATERIAL
List all applicable well construction permits(l.e.County.State.Variance,etc.) .
n. ft. in.
y
3.Well Use(check well use): 17.SCREEN
WaterSupplyWeU: FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
n. ft. in.
❑Agricultural []Municipal/Pubhc _—
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R ft. In.I
—
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 1 ft. cC;O ft.
Non-Water Supply Well: C IF(1_lt.
1! 1C Q d
it. it.
❑Monitoring ❑Recovery —_
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicableZ .,aa�'�
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL— 1 aata7wa eatENT METHOD
R. ft. I
❑Aquifer Test ❑Stormwater Drainage ' —
ft. ft.
Et Experimental Technology []Subsidence Control
oRILLING LQG(aeb additional'boas if �❑Geothermal(Closed Loop) ❑Tracer R TO DESCRIPTION(odor, a sell/reek t2'tx,Brala size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) i IL it. j'){IA+- (A c It -k
4 Il.
4.Date Well(s)Completed: Well ID# _� a,L31, .j IL ���
Sa.Well Locate Totmt ra ' Q(U-SCCI aq:1 R ,30q.7t 1 1A �lTl ,
`�' w 1 tie
ik FONaaeaul cN i cs ( Iicable)
it R 'i `
3 \\ \ t LlGuc "grope, ft, f.
Physical Mittens,[Styr.and Zip 1 21.REMARKS -i�.ttt is 8 N1Z4
County Parcel Identification No.(PIN) Mi fi+ihbPrl P't:-^4M4
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: TQ 1OJ
(if well field,one Iat/long is sufficient) 22.Certif on:
Signat of Certified Well Contractor Date
6.1s(are)the well(s):JPermaneot or []Temporary By going this form.1 hereby certify dui,the wells)war(Here)constructed in accordance
wit 1 SA NCAC 02C.0100 or 1 5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or No copy of this record has been provided to the well owner,
if this is a repair,fill out known well construction Information an ti explain Me 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 i:n 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 foam SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 9k� (ft.) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 4)1003 construction to the following:
10.Static water level below top of casing: LOG (ff.) Division of Water Quality,Information Processing Unit,
ijwater level is abase casing,use"+" c1617 Mail Service Center,Raleigh,NC 27699-1617
�-
11.Borehole diameter: ; ) � (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:
\�C)f�-�A 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: ,(y 1636 Mail Service Center,Raleigh,NC 27699-1636
.
13a.Yield(gpm) I Method of test: f4 14 24c.For Water Supply&laiection 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.
Forte GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.20(3

Wd PAW Seti-Oftoottwill loam
Tarnzra Pearson
Owner: r
Addren ; e �M __.._..�.-
PewitSg
I'hereby certify that the above referenced well,wma grouted in appeals=In,aomedanoe with
all County Well rules.
well ntilter 1(1 ) Signed:
Certl►ficat: Dots
Construction: Grout:
Total Depth:_ ___
Casing
Thickxress• �.--.-
:
Diann:
►SIT ---�---�
Height
Drive Shoe: