GW1--02265_Well Construction - GW1_20240409

. I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used far single or multiple wells
1.Well Contractor Information:
Josh Plemmons 14.WATERZONES I '
FROM TO DESCRIPTION I
Well Contractor Name • R, ft.
4137-A al ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased-wells)OR MINER(if ap iivable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling inc. / it. -7D ft. 0/y in. I psi
Company Name 16.INNER CASINGOR TUBING(geothermal closed-loop)
�?0' 3 _OOt-fI7 FROM ' TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: 6 [ f, ft. in.
List all applicable well coustntction permits(Le.County,State.Variance.etc.)
D. ft. in.
3.Well Use(check well use): 17.SCREEN {
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMtmicipaUPublic H. ft. i°'
°Geothermal(Heating/Cooling Supply) Atesidential Water Supply(single) £t, R. in.
❑Industrial/Conunercial ❑Residential Water Supply(shared) .GROUT 1
FRO18M TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation / ft. COD ft. ���J t I ,
Non-Water Supply Well: ` '1G! L rn f�(�
❑Monitoring °Recovery n' ft.
Injection Well: D. it. I
OAquiferRecharge °GroundwaterRemediation 19 SAND/GRAVEL PACK(fapplicable) J
°Aquifer Storage and Recovery ❑SalinityBarrier FROM TO MATERIAL 1 EMPLACEMENT METHOD
°Aquifer Test OStormwater Drainage
IL ft. l
OExperimental Technology ❑Subsidence Control
°Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach'additioni l sheets if necessary) .
FROM TO DESCRIPTION(mbr.hardness.sell/reck npe.Ream sttq ere)
oGeothermal(Healing/Cooling Return) ((lD�Other(explainunder#21 Remarks) / i6 70 it. Sc _17a u-Ic'i- --
4.Date Well(s)Completed: `29�2*Vell ID# 7D ft- avg." gi--,a_ru
1
Poh
Well Location: �e 2-ft- 3 3 K �,+4`�._e ll
M ni-i-e� it. £L
Facility/Owner Name ' Facility ID9(if applicable) !7. t,.� ` 1-
�3 l€G/ OaL.e F rrsF LLu-c.. : b .. ���y� �� �.
R. £w 'J
Physical ddtess,City,laid Zip 21:REMARKS r A i>`!i ib 1. 2024-
lr.
County Parcel Identification No.(PIN) ..,,....^ r .-� �...,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.CertiFicatiI
(if well field,one lat/long is sufficient)
3 l SZPt31.33 N F'a ' 'wigs— W ,�_
el y-1 ,/,/
Sig of Certified Well Contractor ! Date
6.Is(are)the well(s):,( ermanent or ❑Temporary By igning this form,I hereby certify that the nulls)ins(were)constructed in accordance
with 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 ,10 copy of thisrecordhas been provided to the well ouster.
If this is a repair.fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this fonm 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
6.Number of wells constructed: construction details. You may also attach additio al pages if necessary.
For multiple injection or non-watersupply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS !
9.Total well depth below land surface: Ce?J (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For mutiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following: i
10.Static water level below top of casing: p (ft.) Division of Water Quality,f Informs' n Processing Unit,
If water level is above casing use•,+^ 1(g p 1617 Mail Service Center,Raleigl,NC 27699-1617
11.Borehole diameter: U (in.) 24b.For Infection Wells: In addition to sendidg the form to the address in 24a
12.Well construction method: Yd14 above,also submit a copy of this form within 30 days of completion of well
( construction to the following. 1
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground jection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raid*,NC 27699-1636
Q 24c.For Water SUDDly&Iniection Wells: In addition to sendingthe form to
13a.Yield(gpm) it Method of test: /
the address(es)above, also submit one copy o this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to th i county health department of the county
where constructed. 1
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013