GW1--03178_Well Construction - GW1_20240524

This form can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES
Josh Plemmons FROM TO DESCRIPTION
Well Contractor Name It. ft.
4137-A ft. ft.
\C Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS _ MATERIAL
Clearwater Well Drilling Inc. i ft. �A 0 ft. �0`V h. w C
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
(��`�'• "')�l/3 ( �2.j 1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: F`/L`\C\J GV 11 (�U It. ft. in.
List all applicable well construction permits(i.e.County,Slate,Variance,etc.)
—
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft• ft, in. -
OGeothemsal(Heating/Cooling Supply) residential Water Supply(single) ft. ft• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT —
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. {g'i' It. (\�r1(�� \- m l 1 0
Non-Water Supply Well: ft. 711i ft l t t t� l v sue,
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. It.
❑Aquifer Test ❑Stormwater Drainage -It. ft
.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION jcolor,hardness,N°IUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) ` ft- -:_:11 .9 ft. (C/y)r�/'fi' q� C!t 4'�-'
4.Date Well(s)Completed: --IS ��ell ID# /�1 ft. ��� R X�1�f C ll 1
5a,Well Location: Z0 ram)\ S 1�`7 ft. r 7 ft. t
Sq zft. t 0 sft. . �V)�
— \4'
Facility/Owner Name Facility iD#(if applicable) ' f i.��)
p Dft. ft. j' `�, •C..; 7
LA [ \s Ke + I o n i , e.r&- �V�i S I
. ft. ^
Ph sical Address.City,and Zip ) 21.REMARKS M,`YI 2 z 1024
County Parcel identification No.(PIN) lf`f"
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cert �.h
(if well field,one Iat/long is sufficient) ifJCow:
t a)•5 N cS� CtZ, 32 w , � Li-20 -2Y-
Signat of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or DTemporary By going this form. I hereby certify that the well(s)was(were)constn,cted in accordance
w' l SA NCAC 02C.0100 or 15,1 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or slo ['pi,of this record has been provided to the well owner.
If Ibis is a repair,fill out known well construction information andexplain the nature[tithe
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,.von can
submit one form. 1M SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: L Q��J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(g 200'and 2(100') constntction to the following:
10.Static water level below top of casing: 0D (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: LQ 1 v (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: " ()- construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the formto
(gpm) C� 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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

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Wall Misr SalMinot Cori
20 s .
Owner: &rQceJ
Q,e L New Welly
I hereby certify that tile above mooed well was in appearance in accordance
all County Well n .
vveur �Ytc�o�1S
�j0Sh � %" y -tS- Zq
Grout:Construction
Total Depth; aerfbad
Casing Type: cNc mod:_ m . _
Depth:Casing DePtI4 _ Zu
Dom : Lk I
Drive shoe:
a