GW1--00680_Well Construction - GW1_20240125

I
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 t
FROM TO DESCRIPTION'
Well Contractor Name
it. ft. I
4137-A ft. - ft. I 1 I
NC Well Contractor Certification Number 15.OUTER CASING(for multl-casedwells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft. ft. Lai inn:
Company Name 16.INNER CASING OR TUBING(geothermal clo§ed-loop)
OS
-
Ylo�� -l J'1/'�(� FROM
R, TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: J C"n/ CPIit, j in.
List all applicable well construction permits(i.e.County.State.Variance.etc.) _
ft. ft. in.
3.Well Use(check well use): 17.SCREEN I
Water Supply Well: FROM TO DIAMETER ,SLOT SIZE THICKNESS MATERIAL.
°Agricultural ❑Municipal/Public it. R. in.
❑Geothermal(Heating/Cooling Supply) &esidential Water Supply(single) R. ft. in. I
Dlndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT l
FROM TO MATERIAL ni- EMPLACEMENT METHOD&AMOUNT
R (� tt
�^J
❑Irrigation t . .
Non-Water Supply WeWell: (-�'' `� " ' ' G
°Monitoring °Recovery ft. ft. I
Injection Well: ft. R. '
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD'.
❑Aquifer Storage and Recovery °Salinity Barrier R. R. I
°Aquifer Test DStormwater Drainage ft. R
❑Experimental Technology °Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color.Niftiness,solUroek type.groin size,etc.)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) t tt• it. i ap �4 ( Ke.�i.
4.Date Well(s)Completed: Well ID# R. M X t L
5a.Well Location: Sl I V ear Wn c^ i
co\1ee.x4 10e1 cI 1t, mil f ft cro, j Ue1
,...
Facility/Owner��yyC Name l p+^ Fa�cilit�y IOU(t applicable) R. fL I / E�
O C v 1(Q tie 1 i- C Y W 1.._ � . ft. R. ( J4 N z 5 ,n I rl
Physical Address,,( ess,City,and Zip
21.REMARKS {t-,r- i
_ ►ctexsvn (.�.,..,at.twe..spy, 1
rah-.,. _- . 4("x
County Parcel Identification No.(PIN) `vs=+17 I
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificati n:
t��0om r Flo• I°I N �� W(t a8'la- W --�� 12 -(t? 3
Si are of Certified Well Contractor i?ate
6.Is(are)the well(s): Permanent or °Temporary y signing ibis form.I hereby certti'that the well(s) vas(were)constructed in accordance
with I5A NCAC 01C.0100 or iSA NCAC 0.C.0200 Nell Construction Standards and that a
7.Is this a repair to an existing well: °Yes or No copy of this record has been provided go the well owner
If this is a repair,fill out known well construction Information and explain the nature of the
repair under 021 remarks section or an 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 or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 4O5 (ft.) 24a.For All Wells: Submit this foim withi 30 days of completion of well
Far multiple wells list all depths if different(example-3@200'and���211@100) construction to the following:
10.Static water level below top of casing: V (ft.) Division of Water Quality,inform lion Processing Unit, 1
If water level is above casing,use"+" 1617 Mail Service Center,:
Ralei h,NC 27699-1617
11.Borehole diameter: 1 1 S (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�7�y/� above,also submit a copy of this form;within 30 days of completion of well
12.Well construction method: 1 V iIJ� construction to the following: 1
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 Cen i r,'Ralei h,NC 27699-1636
13a.Yield(gpm) Method of test 1
Cff 24c.For Water Supply&Injection Wells: In addition 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 health department of the county
where constructed.
1
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality; Revised Jan.2013

•
WA Dew SoilLenput Cordes*Son
Omer C,0 06i
mikes koe 24Ciser).-tlick)
Pewit cs5 cnoct •
Ibooby certify that the above referenced well%revolted In appeatenve in madame with. •
all CamtrWeltrales.
Wen Dreier )k)s\im Nmyncos-
Certificate#: L2)-1 - Pr DOW
construction: Groot
Totol Nth; 40S-- 'Met
TYPeLtetia — Thickness:
Casing DaPele Mgt "I"D
Diameter: (0
RV*
Drive Shoe:
GPItt 5