WI0100697_Geothermal Well Construction Record_20240313

can be uvcd Por single or multip wells
1• Well Contractor Information:
Josh Plemmons
Well Contractor Name
4137-A
NC Well Contractor Certification Number
Clearwater Well Drilling Inc.
For Internal Use ONLY;
14. WATER ?nntrc
Company Name
2• Well Construction Permit
List all applicable well consrrucrinn permits (i.e. Cmmiv. State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
XGeothemwl (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑lndustrial/Commercial OResidential Water Supply (shared)
Olrrieatinn
Supply Well:
❑Aquifer Recharge
OGroundwater Remediation
❑Aquifer Storage and Recovery
OSalinity Barrier
❑Aquifer Test
❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
OGeothermai (Closed Loop)
OTracer
OGecxher rnal (Heating/Cooling Return) OOther (explain under #21 Remarks)
d, Date Well(s) Complieted,3 r v
Well ID#
SAL Wev L.ocatioa: Los ik-a 4-
%ki Ce-1 VlA'1
j-+ ,MCI x
t@J -yn
Facil"Khveer Name
Facility iD# (if applicable)
�JL`3 W 1 k r<- 1a
e'rys- A 6dtcss, City, a� Zip Sr C U � Q
Parcel Identification No. (PiN)
Sb. L oduade and Ls>egillude in degrees/sainotes/seeonds or decimal degrees: 22
(if wetl field; am imliong is sufficient) JQ 1 V N Wa' `7
✓q C, �y W
$ial
6. is (ere) the wed(s); APermaneot or ❑Temporary
7. Is this a repair to an existing well: Oyes or 00
ff dW u a repair, fdl ma known weaa/ comstrmrsion ittfortnat un � e\ipluin the nature oj'the
repair under N21 remarkr warn or on the back of thin farm. l ' �+
S. Number of weds rosstrudL ed: (0) 't" D G t
For multiple inr)aettrm or non -muter smiy4i, wells ONLY with the same construction, you con
smbM/! amr fa/m.
ft, ft.
n, n•
ft. I ft. in.
ft, l ft. la.
ft. ft.
a• n.
ft. ft.
n. n.
rt- n.
n. ft.
n, ft.
rt. ft.
n. n.
ft. ft.
ft. ft.
of Certified Well Contractor
j-�3 D4
bate
Hy going this form, 1 berebv certify that the %ell(s) vas (were) comtnwted is accordance
n'' o ISA NCAC 02C,0100 or 154NCAC 02C ,02to Well Convtrucn m Stundwris and dwl a
Yy of this record has been pruv"d to the Heil under.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
(•otistruction dt^tails. You may also attach additional pages if necessary.
SUBMITTAL. INSTUC'TIONS
9. Total well depth bellow bad surface: (ft.) 24a. IER AU Wells: Submit this for,u within 30 days of completion of well
For mu/ttpfe wielb ho00drptlu ifd0orcni ("ample- *200 •and 2(g1W) 'wristruction to the following:
I a. Static water level below top of casing:
If wester level is above cawft, use "+ "
11. Borehole diameter. (Ire.)
12. Well construedoo method: _
(i,e, auger, rotary, cable, direct Pugh, etc.)
(ft.) Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. 1 g luiectiort Welr : Its addition to sending the form to the address in 24 above, also subnut a copy of this torn, within 30 days of completion of wet c ultstruetion to the following:
FOR WATER SUPPLY WELLS ONLY:
iivision of Water Quality, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
13s. Yield (gpm) Method of test: 24c. Water �uaply & Injection W (Its In addition to sending the form to
the address(ea) above also submit one copy of this form within 30 days
13b. Disinfection type: Amount; completion of well construction to the county health department of the coo
where constructed.
Form OW-1 North Carolina Dep
artment of Environrrrent and Natural Resources - Division of Water Quality
Rev i—A

CONSTRUCTION RECORD
1'hts thrrm con be used for single or multiple welts
i. 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 #: Y I — V I MPO(p
List all applicable r+ll conrowclian prrmits (i.e. Count-, State, t arionr e, etc,)
3. Well Use (check well use):
OAgriculturad OMunicipal/Public
0t,rcothemtal (Heating/Cooling Supply) ❑Residential Water Supply (single)
Olndustrial/Commercial OResidential Water Supply (shared)
Non -Water Supply Well:
0monitorintt ORecovery
OAquifer Recharge OGroundwater Remediation
OAquifer Storage and Recovery ❑Salinity Barrier
OAquifer Test OStormwater Drainage
OExpet mental Technology OSubsidence Control
OGeothermal (Closed Loop) []Tracer
OGeotherml (Hestmg/CoolinR Return) ❑Other (explain under #21 1
4. Date Wetl(s)Compteted:J-
Sr. Well Location-
f: d' V
Factlay/owner Name Fa 'dity ID# (if applicable)
"r .
Phnscal Address, 04, and Z
CO—Y Parcel identification No. (PiN)
5b. Latitude sad Longitude in degreestndautes/secoods or decimal degrees:
(if Wen %Yt'd',�one
�taV� is sufffficwnf) 1 j �) n`
6, Is (are) the wellisl: *ermamot or OTemporary
7. Is"a hair to an existtng well: Oyes or �No
If this u a repair, Jill out km&w well construcoon information and explum the nature of the
repair under #21 rentorb aectwn or on the basin of this form.
8. Number of webs constructed: 2- a LM f `Y
Far vwkq le uVeco oo or ran -}toter supply weals ONLY mth the same consirrudon, you can
svhmn oae ja m.
For internal Ilse ONLY:
22. Certification:
Si ature ofCertified Well Contractor Date
y signing this form, i hereby certih, that the Nell(s) %w (Uvre) co&-+Wucted in accordance
with 1 SA NCAC 02C .0100 or 114 NCAC 02C .0200 Well Comiruc6unt Stwuhwds and that a
copy of this record hw been provkled to the well owner.
23, Site diagram or additional well details:
You may use the lack of this par to provide additional well site details or well
construction details. You may also attach additional pages if necessary,
SUBMITYAL INSTUC" PIONS
9. Total well depth below land surface: (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple rw1h list all depths tf,40imenl (aample- JIVOO' atd i@41W) collstr uetion to the following:
10. Static water level below top ofcasiag: (ft.)
If water tenet is above casting, use .,+ "
11. Borehole diameter: (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, ode.)
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b, For Iniectiou Welts; In addition to sending the form to the address in 2'
above, also submit a copy of this form within 30 days of completion of wl
construction to the following:
Division of Water Quality, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24c• 1FAr Water Suooly & Iota « . ,
u 'i its In addition to sending the four, t4
fire address(ea) above, also submit one copy of this form within 30 days
13b. Disinfection type: Amount: completion of well construction to the county health department of the n
where constructed,
Farm GW-1 North Carolina Dep
artment of Environment and Natural Resources - Division of Water ouality