WI0100714_Geothermal Well Construction Record_20240320

�L>G [RECORD
A n's form can be used for single or mulhple wells
1. Well Contractor Information:
Josh Plemmons
Well Contractor Name
4137-A
NC Well Contractor Certification Number
Clearwater Well Drilling Inc.
Company Name 2. Well Construction Permit #: _tt •• tt T--- `op-1 L' f
List all applicable Hell construction permus �, e, Coinit
Y,State,
fmiance, etc.)
3. Well Use (check well use):
[]Agricultural ❑Municipal/Poblic
' Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial OResidential Water Supply (shared)
Supply Well:
OAquifer Recharge
OGroundwater Remediation
OAquiler Storage and Recovery
❑Salinity Barrier
DAquifer Test
❑Stormwater Drainage
DExperimental Technology
0Subsidence Control
DGeothermal(Closed Loop)
OTracer
OGeothermai (Heating/Cooling Return)
OOther (explain under #21 F
4. Date Well(s) Completed- �`� Z �2 Well ID#
Sa. Well Location:
Ucwr" --� rzho-1
Facility/Owner Name Facility ID# (if applicable)
U4 Rom it e Ed she1A ((_e
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(iffwell field, one lat/long is sufficient) I t +
6. Is (are) the well(s): Permanent or ❑Temporary
7. Is this a repair .to an existing well: DYes or 'V10 /
Jf this is a repair, fill our known well construction information and explain the nature of the
repair under Oi21 remor63 section or on the back of this form.
8. Number ofwells constructed: � (4 13
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
r
internal Use ONLY: __71
14, WATER ZONES
FROM
TO
D CRIPTION
ft,
ft.
ft.
ft.
I S. OUTER CASING for
multi -eased welts)OR LINER' if a ` licable
FROM 70
DIAMETER I
THICKNESS I MATERIAL
ft. ft.
in.
Ili INNER CASING OR TUMINC eothermal closed-Ioo
FROM
To
DIAMETER
THICKNESS
I MATERIAL
ft,
I ft,
I in.
n.
ft.
in,
17. SCREEN
FROM I
TO I DIAMETER I SLOTSIZE I THICKNESS I MATERIAL..
ft.
f6
In.
ft
fl.
in.
18, GR0I1T
FROM
I TO
MATERIAL
EMPLACEMENT METHOD & AMOONT
ft.
ft.
ft.
n.
ft.
ft,
19. SAND/GRAVEL PACK if a' licable
FROM
TO
I MATERIAL F
EMPLACEMENT METHOD
tt.
fr.
ft.
ft.
20. DRILLING
LOG attach additional sheets If ntcesfa
FROM
I TO
DESCRIPTION color,4ardaess wiYroc tales da
ft'
rt.
t-1C
ft.
ft.
ft.
ft.
ft.
ft.
ft.
fr.
R.
ft.
21'REMMRws
22.
Well Contractor
S J2D -,,q
Date
By signing this f rrm, 1 hereby certfy that the well(s) 4= (sere) cacrtructed in accordance
will, 15A NCAC 02C,0J00 or 15A NCAC 02C,0200 Well Constractiott Standards and that a
copy of this record has been provided to the Nell onwer,
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
constnlction details. You may also attach additional pages if necessary,
SUBMITTAL INSTUCPIONS
9. Total well depth below land surface: (ft,) 24a. E2r AM Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different (example- 3@200' and 2@100) construction to the following:
10. Static water level below top of casing; (ft,) Division of Water Quality, Information Processing Unit,
lfwater level is above casing, use "+ 1617 Mail Service Center, Raleigh, NC 276994617
11. Borehole diameter: (In.) 24b. For 1plection Wells: In addition to sending the form to the address in 24a
12. Well construction method:
above, also submit a copy of this form within 30 days of completion of well (".e. eager, rotary, cable, direct push, etc.) construction to the following:
Division of Water Quality, Underground injection Control Program,
FWATERUPPLY WELLS ONLY; 1636 Mail Service Center, Raleigh, NC 27699-1636
Method of test; 24c. For Water Sunniv & Iition to sending the farm to
nfection Wellsthe addresses) above, also submit onecopyofIn dthisarm within 30 ays of
type: Amount; completion of well construction to the county health d a where. constructed, ep rtment of the count
Form GW-1 North Carolina Department of Environment and Natural Resources
Division of Water Quality
n .,_