GW1--00681_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 l l I
FROM TO DESCRIPTION
Well Contractor Name R. R. I !
4137-A ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)ORLiNER(if Bp Iicable)
FROM TO DIAMETER! I THICKNESS MATERIAL
Clearwater Well Drilling Inc. J ft. t? •ft. ( Tiin: VC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
h �7
FROM. TO DIAMETER! THICKNESS MATERIAL !
2.Well Construction Permit If: OSS-AZJa3- /c3 7o ft. ft. Sin.
List all applicable well construction permits(i.e.Comm.State,Variance,etc.)
R, ft. lin.
3.Well Use(check well use): 17 SCREEN - ! I
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE! THICKNESS MATERIAL
ft. ft. In.
°Agricultural °Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R. R. In.
°Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Obligation / it OD R. eefte(:><
Non-Water Supply Well: R, ft �d ' "'
°Monitoring ❑Recovery ,
Injection Well:
R. ft. i
❑Aquifer Recharge OGroundwater Remediation 19 SAND/GRAVELPACKUf applicable)
FROM TO MATERIAL; I EMPLACEMENT METHOD
°Aquifer Storage and Recovery °Salinity Barrier it R !
❑Aquifer Test °Stormwater Drainage I ,,
ft, ft.
❑Experimental Technology °Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary).
°Geothermal(Closed Loop) °Tracer FROM TO DESCRIPTION(color.hardness.son/rock type,grain size.etc.)
°Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) p` F3 ft Sat)l' T�Na v/
//// q Well ID# 0 3 R a/g . D� /Y
4.Date Well(s)Completed: I- 7-o(�
n_� 9/62 R. ft
5a.Well Location: /O�M7T) �G l/6h c9/3' a rit)u-e,,I,..__R. '
radd Ales li- go o -� ft ft i.-v a,! i;s, r•7o�.
Facility/Owner Name ' Facility lD#(if applicable) ft. ft. s y a.�,l�"i rI f
103 P77/l OOd /Or. ,ILA r• P ," 1
ft. ft. � 4 a CU'24 1
Physical Address,City,and Zip 21.REMARKS
driis,ti*L,<:__ .,, I
/et)dei:soo QZa 3n[o5.?(oore I V :�:Ar A.; URN 1
County Parcel Identification No.(PIN) -
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certific on:
(if well field,one lattlong is sufficient)
0.5/31, '33W 9 N Y 150 o7. 73 W _ t -ct-02q
Si of Certified We Contractor ( Date
6.Is(are)the well(s):iftermanent or ❑Temporary By s' ring this form.I hereby certify that the sell(s)uns(were)constructed in accordance
wit ISA 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 Mkt o co of this record has been provided to the uell ownerr
If this is o repair,fill out known well construction information and explain the nature ofthe
repair under#21 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: 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 j 1
9.Total well depth below land surface: aes (ft) 24a. For AU Wells: Submit this form withi 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3( 00'and 2@100) construction to the following: !
10.Static water level below top of casing: ee D (g,) Division of Water Quality,Inform tion Processing Unit; 1
If surer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 1
11.Borehole diameter: /t� (in.) 24b.For Injection Wells: In addition'to sendingn the form to the address it 24a
// above,also submit a copy of this form withi 30 days of completion of well
12.Well construction method: h9 taly construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground njection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent i,Ralei h,NC 27699-1636
t: 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) /5 Method of test In ddition to sending the form to
�f the address(es)above, also submit one copy f this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the{comity health department of the county
where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quail • Revised Jan.2013

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Mere*car*tbat lite above referenced wis pond in appearance lt,1 accordance wIth •
all Comty Well rules.
Well Dillter_._ • S' •
Daft Y
C.onstradbm: Quit
Total Depth:,,,., Type:
Casing Type422e_
ei*Deptiuj .
Dauer:
Height
Drive Shoe: