GW1--00675_Well Construction - GW1_20240125

VN)et,I -3'- 1
WELL CONSTRUCTION RECORDi.
This form can be used for single or multiple wells For Internal Use ONLY:
I.Well Contractor Information: I
Josh Plemmons 14.WATERZONES I
FROM TO DESCRIPTION
Well Contractor Name R R
4137-A ft. ft.
NC Well Contractor Certification Number 15.'OUTER CASING(for multi-eased wcus)OR LINER(flap*able) • -
FROM TO DIAMETER I ' THICKNESS MATERIAL
Clearwater Well Drilling Inc. I tt. I 0 tl: I t, ip•,i
Company Name 16.INNER CASING OR TUBING(geothermaldo ed-loop) � -
tisc /7093- i 35/ o FROM TO DIAMETER I' THICKNESS MATERIAL
Z.Well Construction Permit#: 6r/V( ItJ R. ft in. .
List all applicable well construction permits(i.e.County,State.Variance etc.)
ft. rt. in.+.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE - THICKNESS MATERIAL
DAgricultural OMunicipal/Public n• R. in, l
❑Geothermal(Heating/Cooling Supply) X.esidential Water Supply(single) ft. fi in. ('
°Industrial/Commercial °Residential Water Supply(shared) 14.0r UT I: i
TOUT
°IrrigatioII R. 9r� ft.
MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: l Jft. l� 0 6
X�1 K ;) �,
❑Monitoring ❑Recovery N• ft.
Injection Well: ft. ft,
I
❑Aquifer Recharge - ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applieable) -
°Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
tt. R.
°Aquifer Test OStormwater Drainage
°Experimental Technology °Subsidence Control ft.
OGeothetmal(Closed Loop) °Tracer 20.DRiLLiNG LOG(attach additional sheets if nedetsary)
FROM TO DESCRIPTION(color,beldam.soWrock type,gtytn an.etc,)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)- 1 H- 0 ft. /�)� [ .-(I_ S&
4.Date Wells)Completed: Well ID# QZ ) ft ((�i R. rC�14' ,� c
Sa.Well Location ` '071 R• 5"" 6 m C ej101
eft' l DOS.n.
2020 &I)Ct A'S ft. ft. .Facili !Owner NameI ' �.® "
tY Facility ID#(if applicable) C
TuA-+-\e_ ft, f AN 2 5 2024
Physical Address,City,,aandd Zip
C���1 �]l 1�� 21.REMARKS figt rasa+P•n Pr•:-
'`_t:` vr:r�
County Parcel Identification No.(PIN) ,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifies• n:
(if well field,onee^tat/ong is sufficient) p y ,t
e �CS • 1-.-1 N (� 'OS l 1`'I .1`t"- w G.L.- /0C - 1 3 "c?c
Si Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ElTemporary By lug this form.I hereby certify that the;well(s)wOs(Were)constructed in accordance
i fit 15A NCAC 02C.0100 or ISA 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 mill owner.
If this is o repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis 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 infection or non-water supply wells ONLY with the same construction,you can
submitonefarm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: LOOS- (it,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(32200'�and Z@IOO) construction to the following:
10.Static water level below top of casing: COO. (ft-) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" t` 1617 Mail Service Center',Raleigh,NC 27699-1617
11.Borehole diameter: ( (in.) 24b.For lniection Wells: In addition to sending the form to the address in 24a
t_ above,also submit a copy of this forni within 30 days of completion of well
12.Well construction method: �+(IiA construction to the following: I
(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,Italeigp,NC 27699-1636
13a.Yield(gpm) i Y Z Method of test: klui 24c.For Water Supply&Infection Wells: In a dition to sending the form to
the address(es) above, also submit onel copy o this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county th department of the county
where constructed.
Form GW-i North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

•
WdI Nearegaden
ovaler: aQ 0am" _ New Weil:
r
thereby Earti(vfnat the above referenced well vas grouted in appearanzein • with
all r .
wen Dicer, _ P t511'`ron S';., .: ,•
tea#: y-131 -A _ Datoo ,
. i
Con tom,: Cleat
i.
1N e,t t At\
Total l h; toOS -k-Cashig'rom pvc TilicknEss: CD(
Casing Depth 0 Depth: ca.-2
tWdghtnaldeo'��
,---
Height
Drive ,
opat
1