GW1--00531_Well Construction - GW1_20240118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons FROM14. AR TO DESCRIPTION
Well Contractor Name R. ft
4137-A rt. it I
1S.OUTER CASING(for multi-cased wells)OR LINER Of ap lkable)
NC Well Contractor Certification Number FROM TO DIAMETER ' .TIHCICIVFSS MATERIAL
Clearwater Well Drilling Inc. l it. — j ft. t, �\ n. I ‘--)\70,
16.INNER CASING OR TUBING(geothermal closed-loop) V
CompanyNatm FROM TO DIAMETER THICKNESS MATERIAL
V
2.Well Construction Permit#: u E t2"Y�13 d OO rr B. R. in.
List all applicable well construction permits(i.e.Counry.State,Variance,etc.) •
R. it in.
3.Well Use(check well use): 17.SCREEN • 1
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Water Supply Well: R. ft. in.
DAgricultural OMunicipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
if. ft. in.
Olndustrial/Commetcial 0 Residential Water Supply(shared) 18.GROUrM FRO TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
❑Irrigation , ft. 20 ft• e:� ic1� InCiLicl
Non-Water Supply Well: ft, R.
❑Monitoring ❑Recovery
Injection Well: ft. it.
[Aquifer Recharge °GroundwaterRemediation 19.SAND/GRAVELPACIC(_Ifapplicable) i
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery °Salinity Barrier ft ft.
[Aquifer Test ❑Stormwater Drainage ft. R.
0Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets If necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color.haulm,sail/rock type,grain sire,etc.)
OGeothetmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 ft. 03 it. 1(A 4'I(AA rk.
n`ri l'�I
4.Date Well(s)Completed: Well ID# Q-- " VL-ft.ft. ft ''J
Sa.Well Location: I �j e ft- ft.
�J .ha I
I Mi rcck , B. it F IF.:
«Vi,,�Facility/Owner Name Facility 1D#(if applicable) ft. ':, '..-4''..-4'�u^u '"
,Aqi, Siadin 9 W al ft. ft. JAN 1 S 4UZ4
Physical Address,City,and Zip 21.REMARICS i IiJ�M
.�1 fir n Jr) Into i iiA.n.?....t n
Patcel Identification No.(PIN) Li"wy---
County
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certiflc on:
(if well field,oneon latt long is sufficient)uffi (jy� C� �yC L t I -I S a„3
l5t3llc-I61.3t N WalLt/tg1, b / wy i !
L Si of edified Well Contractor I L Date
6.Is(are)the well(s): Permanent or l�i!'emporary By si 'ng this form.I hereby cerhk that the nvell(s) (were)constructed in accordance
\ with SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or ONo co of this record has been provided to the'well ouster,
If this is a repair.Jill am known well construction information and explain the nature of the .Site diagram or additional well details:
repair under#ZI remar/s section gran theback of this farm. 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-watersupply wells ONLY with the saute construction,you can SUBMITTAL IN$TUCTIONS
9.Total well depth below land surface: (f t�)
submit ono form.
24a. For All Wells: Submit this form with' 30 days of completion of well
� construction to the following:
For multiple wells list all depths ifd�rent(example-3@g20`0''and 2@100�
10.Static water level below top of casing: W fl (ft.) Division of Water Quality,Inform lion Processing Unit,
If mster level is abate caring.use"+" '
1617 Mail Service Center,Ralei'ggh,NC 27699-1617
11.Borehole diameter: W 1 (in.) 24b.For Injection Wells: In addition to sen ' g the form to the address in 24a
above,also submit a copy of this f arm with' 30 days of completion of well
12.Well construction method: �/jt�y constntction to the following:
(i.e.auger,rotary,cable,direct push etc.) Division of Water Quality,Und a rgrounc Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Rale gh,NC 27699-1636
24c.For Water Supply&Infection Wells: Ir addition to sending the form to
13a.Yield(gpm) Method of test: the address(es) above,also submit one copy of this form within 30 days of
completion of well construction to the( county health department of the county
13b.Disinfection type: Amount: where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013

INA DOW Sall4iout CardilloNon
S eedal ety eW
thereby 60114fitit the aboverefecenced well-was grouted in appearancein aocoTdaote with •
all Gam Wall mks.
well atter s-
new
caasaudiaa: Quiz
Total DerAtc -
Casing Typ9 . Type: Cexit&P
Ibid
Caging Depth: Deplb:
Diarnetw_tiLik--