GW1--03187_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Josh14,WATER ZONES
Plemmons
FROM TO DESCRIPTION
Well Contractor Name It. ft.
4137-A ft. Ii.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wdl!)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. 1 ft. f.-. ft. Lo li `>
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
<` FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: L JS_ (9014- - C I:37 ft. in.
List all applicable well construction permits(i.e.County,State, Variance,etc.)
-
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS _ MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) KResidential Water Supply(single) It. It. in. -
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation I IL r 11\\v It. c
Non-Water Supply Well: C.C�((Yc at I�I iLkd __-,
ft. ft.
❑Monitoring ❑Recovery --
Injection Weil: It. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable"
FROM TO MATERIAL EMPLACEMENT METHOD❑Aquifer Storage and Recovery ❑Salinity Barrier _It. II.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
-
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothcrtnal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) ` ft• 1-Yu ft• (..t 1l `i- C ri li
4.Date Well(s)Completed: Well ID# ) R ��'� ft. n4 /a,(l� L 1
l l.JAI(Y.-C J ,
P:34 ft.
5 n. ( c kAt.l
5a.Well Location:1 ft a lC'. f. v
12U 0\60 S Sl� tL nl��rl� ..
rt. n. /
Facility/Owner Name Lit-4t_2 Facility ID#(ifapplicable) It It `iiA'I 2 " ?024
i 31 T*- I(.. Rd ft. ft. j sr*
Physical Address,City,and Zip 21.REMARKS
eY neiS '1 '
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer. ation:
(if well field,one tat/long is sufficient)
r
35 3' ►:5. ►�: N S''a 20 67, 3�tit W 1 .---1.---,------ 14'a y 0? q
Sig of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary 3 signing this form,I hereby certify that the well(s)was(were)constnhcted in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standard,and that a
7.Is this a repair to an existing well: ❑Yes or arid
copy of this record has been provided to the well ouster.
lf this is a repair,fill out known well construction information and explain the nature of the
repair under#2!remarks section or on the back of this farm. 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
, ''tn��..�
9.Total well depth below land surface: ll,1�` (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3@200'and,2@I00') construction to the following:
10.Static water level below top of casing: lk'V (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I O 24b. For Injection Wells: In addition to sendingthe form to the address in 24a
11.Borehole diameter: � (in.)
!� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: IV!CU 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(gpm) 1 Method of test: RIC{ 24c.For Water Supply&Injection Wells: In addition to sending the form to
1 the uddress(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount:
where constructed.
form G W-I North Carolina Department of Environment and Natural Resource,-Division of Water Quality Revised Jan.2013

aiwa
4121ali
r1131111AISPAA
?3-) ualaueK1
--70-7-Aiba&Teo
Cd-3(14&WO
A-U-2w7 ---Tr °420a5 VAL
:gloat) xotprusuty,
Ago
*Patft W9SQ_UJJJ? ;4811141 IRPA
Vattu 1PPA Aluno3 tie
vim amepxwe tit amemaddeUI path sem Nan paottavajaz 4nocia *RR 4010&watt
1_2 - Axtuad
ma9N1 ( Or/C :34tim°
. •
1100119001.7 snowsps mow was