GW1--00676_Well Construction - GW1_20240125

WELL CONSTRUCTION RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons 14.WATER ZONES I I .
FROM TO DESCRIPTION
Well Contractor Name ft- B- I
4137-A ft. R.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR.LINER(if op,licable) .
FROM TO - DIAMETER I ` THICKNESS MATERIAL
Clearwater Well Drilling Inc. / ft. /iv ft• in.; I Steel
•
Company Name 16.INNER CASING OR TUBING(geothermai cloted-loop)
r) �� FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: OSS r �GJ (03 ft. ft in
List all applicable well construction permits(i.e.Caunty.State.Variance,etc.) in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER .SLOTSIZS THICKNESS MATERIAL -
°Agricultural °Municipal/Public ft. R. In. I
°Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ft' in. I
DlndustriallCommercial °Residential Water Supply(shared) I MROUT TO
/M�ATEtwu,I L EMPLACEMENT aCE,M/ENT/MerHOD&AMOUNT
°Irrigation l 1t' ZO (L l � f'1/1 I/ IJ,{r.. 7
Non-Water Supply Well: R.
°Monitoring °Recovery
Injection Well: ft. R. i
°Aquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL' EMPLACEMENT METHOD
°Aquifer Storage and Recovery °Salinity Barrier R. •
R. I'
°Aquifer Test OStonnwater Drainage ft, ft, j
❑Experimental Technology °Subsidence Control 20.DRILLING LOG(attach additional sheets if n4essary).
°Geothermal(Closed Loop) OTmeer FROM TO DESCRIPTION(color.hirdoess,sowroe&type,grain Ate,etc.:
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) I D. 7 t' fe• .ca..i i a f lL
4.Date Well(s)Completed:� Well Wit //t f ".307R' V leSa.Well Location:C(rae Really[LC ?60.7 D. 3'f D• ti I
akrR. arm r(ai/i/61
'boa / /,ri11/efs LCC ft.
Facility/Owner Name Facility ID#(if applicable) I I m"iL-: �'' '^ , . ,
,,/;? fid-ifl t�,/, fL ft. I
r I t k_ �7
pA [
Physical Address,City,and Zip 21.REMARKS I �61'+ d t:�L�4
1-/P 7,71rcnn lflibrT ic.1 3.___ .
County Parcel Identification No.(PIN) _,p '''rA LI-1A
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:(if well field,one iat/long is sufficient)
<35-`. t 7a7,71, N f,3 Q7, SI? w I /� 2 -4
tt,� Signature o edified Well Contractor Date
6.Is(are)the well(s):upPermanent or °Temporary By sign'g this form.I hereby certify that the well(s) 'as(were)constructed in accordance
with A NCAC 02C.0100 or ISA NCAC 02C.0200 ell Construction Standards and that a
7.Is this a repair to an existing well: °Yes orVo copy ofhis record has been provided to the well ovine
If this is a repels,fitl out known well construction information and c.rplain the nature of the
repair under#21 remarks section or on the back of this faun. 23.Site diagram or additional well details:
You may use the back of this page to provide dditiodal well site details or well
8.Number of wells constructed: construction details. You may also attach•additiumai pages if necessary.
For multiple injection or non-water supply wells ONLY with the some construction,you con
submit one fonn. SUBMITTAL INSTUCTIONS
4O C
9.Total well depth below land surface: (ft.) 24a. For Al Wells: Submit this fawnI 'within 30 days of completion of well
Far multiple wells list all depths/fderent(example-3@200'and 2@100' construction to the following:
10.Static water level below top of casing: 7 t7 (ft.) Division of Water Quality,information Processing Unit,
If water level is above casing,use"+" I 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 6,/o (in.) 24b.For Infection Wells: In addition to send ng the form to the address in 24a
Ley above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: Y�7 t t rt/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Undelrground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: j� 1636 Mail Service Center;Ralei:h,NC 27699-1636
13a.Yield(gpm) ! Method of test: 1�/ 24c.For Water Supply&Injection Wells: in addition to sending the form to
the addresses)above, also submit one!copy ,f 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality: Revised Jan.2013

Well Draw Solfierout Cad,lakeon
doe, "'tally Lc
Ownert.ig2.(2...611-ader , New
ppair
Paint 0-55 a70;13 i3b
fly catifythat the above-rammed wallas grouted in appesannce in acx 1with
all ComyWell.mks
Well Miner: 1/4504 Pfrfiwroms
Certificate*: 137 "4-
Da* ,
Mastro:dam Grout
Tend Dere: C-1°C Type: e effie-AAL
Casing Type Sit el Thickness: Ii
Casing Depth: g Depth:
Dinneen':
Drive Shoe;
GPM: A