GW1--05780_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For internal Use ONLY:
1.Well Contractor information: L
Josh Plemmons 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4137-A n. a. —
NC Well Contractor Certification Number 15.OUTER CASING(for malt(-cased wefts)OR LINER(If applicable)
FROM TO DIAMETER THICKNESS MATERIAL Clearwater Well Drilling Inc. / ft, qa ft. IV 1/ c` in Pc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
� / n FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: d 0,9 3 -t�737/ -7 --i ) q, - 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
❑Agricultural OMunicipal/Public ft. ft in.'-
OGeothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft, in.
❑Industrial/Commercial /residential Water Supply la.GROUT
pp y(shared} FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Obligation
tL H, �pfyl,1)� �)
Dl Non-Water Supply Well: / •tiff�� fM� �/
OMonitoring ❑Recovery ft. ft.
injection Well: ft, ft -- -
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If appllcaI
❑Aquifer Storage and Recovery ❑Salinity Barrier vRoM TO MATERIAL EMPLACEMENT METHOD
ft. H. --I
❑Aquifer Test ❑Stormwater Drainage _
❑Experimental Technolo ft. ft.
SY ❑Subsidence Control
20.DRILLING LOG(attach additional'beets If aecseauy)
❑Geothermal(Closed Loop) OTracer
FROM To DESCRIPTION(color,Yardmen,!aIYrach tape,grela size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Outer(explain under#2l Remarks) / ft• %t2 ft. s/r�
LI')i7 ,/ „/ l
4.Date Well(s)Completed:O -67 "o2�Well lD# J�a ft. .0 ft, �O',�Kp�C/L/allik. r
5a.Well Location: 3 3�3 R. (/( L t
Pi nnG�ele. Qr u's� 3Y 3". 4405 ft' raPde
C-11-S C 1 ft. IL +�
Facility/Owner Name 't' Jj C/ Facility ID#(if licable)
/�,31� 16,
Tifi-ayicJ, j,l _ tt. —
G(Y�S 1 r\L f ft. ft
Physical Address,City,and Zip •--u• / J....ad
21.REMARKS
-)6'/(:-'60/' SEP 2 d 2024 •
County Parcel identification No.(P!N)
5b,Latitude and Longitude in degrees/minutes/seconds or decimal degrees: tr.`,...
A. ,• ' n• ,y t,
(if well field,one!at/long is sufficient) 22.Certifies D
-------------------
Signatu f Certified Well Contractor Date
6.Is(are)the well(s): ermanent or OTemporary
By s' ning this form. 1 hereby certify that the well(s)was(were)constructed in accordance
wi i5A NCAC 02C.0100 or 15A NCAC 0.1C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or No copy ofthis record has been
provided to the neil owner.
1f 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 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 o'non-wafer supply wells ONLY with the same construction,you cot
subrnitoneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: T 05 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdin rent(example-3Q700'an-d2gl00y construction to the following:
10.Static water level below top of casing: /!7 C (ft.) Division of Water Quality,Information Processing Unit,
1f water level is above casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: /J (in.) 24b. For injection Wells: In addition to sending the form to the address in 24a
L/� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Yo! 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: A ! 24c,For Water Supply&injection Wells: In addition to sending the form to
` the address(es) above, also subunit one, copy of this form within 30 days of
136.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

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Omer PjnnUr(I4. _ -LLc `,hn - .. .
Penntu?Oa3 ail 799
I hertby andlyther the shove rekrenced wire graved in in►'macrame
vidt
all Ceontr tiMet
Cam: q/37-A' _ Date Grouted:
nal Depth: (6PS— 111"--aeafid
Casing'rne4 Vc InddlneeK m/1yd _
— a
cawingga ' ---
GPM:, /G