GW1--00677_Well Construction - GW1_20240125

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.We;Contractor Information:
Josh Plemmons 14.WATERZONES I I
FROM TO DESCRIPTION I '
Well Contractor Name ft. ft. I -
4137 A ft. ft. I ,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If a Usable)
FROM TO DIAMETER I ' THICKNESS MATERIAL
Clearwater Well Drilling Inc. / R. 4` R. in. St-eel
Company Name • 16.INNER CASING OR TUBING(geothermal closed-loop)
�/ 10 3 - /35 FROM TO DIAMETER I THICKNESS MATERIAL2.Well Construction Permit ft: U ft. ft. tn. —
List all applicable well construction permits(i.e.County.State.Variance,eta) I
R. ft. in.
3.Well Use(check well use): i.
17.SCREEN Water Supply Well: FROM TO DIAMETER .SLOTSIZII THICKNESS MATERIAL •
DAgricultural IMunicipal/Public ft. ft. in. 1
°Geothermal(Heating/Cooling Supply) residential Water Supply(single) R, ft. in. I
❑lndusttiaUCommetcial [Residential Water Supply(shared) IS.GROUT I
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑IniWate a. y i
Non-Water Supply Well:
ft. Cu�t n ilf in/id
vt
ft. R. I
°Monitoring ❑Recovery
Injection Well: ft. ft. I
°Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(If applicable) I
°Aquifer Storage and Recovery ❑Salinity Ranier FROM TO MATERIAL ; EMPLACEMENT METHOD
ft. ft. !.
°Aquifer Test OStotmwater Drainage
ft. ft.
❑Experimental Technology °Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) °Tracer PROM TO DESCRIPTION(color,tuirdnms,solVrock type,grain alze,etc.)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) / fa g/ it. .SCt/� ' t `1-
4.Date Well(s)Completed: Well ID# �l 1t Ill R. ���Ld /�k.
I
Sa.Well Locatio
I V R. 7ga R' ,,t (A (
/eF#1 ft. o7a7.S rt. l%% ifil
��(J,0 tinders ft. ft. / ,L.� _Facility/Owner Name Facility IDS/(if applicable) I. ft. -..� T �Z
;224 Tu.-lit D �1 s y�'�,A �': F„ e
R. R. �' „' a r. .s Pr.®,ms
Physical Address,City,and Zip 21.REMARKSI I .
I JFiIV 2 i 7Q7/t
r
County Parcel Identification No.(PIN) rocs 22.Certific jd xv:;%1s.�t.r c•..c yf)U N
i,ra•w:.
5b.Latitude aid Longitude in degrees/minutes/seconds or decimal degrees: n: ��' i CIE
(if well field,one latllong is sufficient)
35 t 35175"al� N ga t3 � 92 De W ,7 /2- 2 v 3
Signs ofCettified Well�ontmctor Date
6.Is(are)the well(s):Xermanent or °Temporary By si wing this form,I hereby certify that the nell(s)sins(were)constructed in accordance
wit 1SA 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 l fo co 'of this record has been provided to the s vlI owner
If this is a repair,fi#out known well construction information and lain the nature of the j
repair under fa 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: 0 construction details. You may also attach additiolrtal pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total welldepth below land surface: a.5— (f.) 24a. For AU Wells: Submit this form with' 30 days of completion of well
For multiple wells list all depths ifdfJerent(example-3 00'and 2C100) construction to the following: 1
10.Static water level below top of casing: �� (ft.) Division of Water Quality,InformsLon Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Ilalei NC 27699-1617
11.Borehole diameter: 641 (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; i t/11� , construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground njeetion Control Program,
FOR WATER SUPPLY W�E-LLS ONLY; �A 1636 Mail Service Cent r,Ralei NC 27699-1636
13a Yield(gpm) `s Method of test '`" Q 24c.For Water Snooty&Iniection Wells: In ddition 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 iealth department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

1NA Dew ►u t Callikation
202.0 giA1lelers
Pennit ems - /35
'hereby ceitifythat the abo e Iticenced mos grouted inappearance In:.., , :> with.
all County Well rtdes- !
wea 101A Plum ,:
eery: U/57-A- l ,1: -
Co : Gloat
Tend Depth;
2Z 5- Type: nn- -
Casing Typesff zl Thickness: /71-4604
Casing : Q/ Dept:1r
Diameter
DiveSloe:
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