GW1--03198_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:
Josh Plemmons 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4137-A ft. ft. -
NC 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. 5,5- rt. C+..,..,,fey in. p
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) !
�R[ / FROM TO DIAMETER _ THICKNESS MATERIAL
2.Well Construction Permit#: tr%�.3 - C:0 9-'7 ft. 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 _
❑Agricultural ❑Municipal/Public ft. ft. in. _
❑Geothermal(Heating/Cooling Supply) ) Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM ( TO ( MATERIAL _ EMPLACEMENT METHOD&AMOUNT
❑irrigation / ft. GO H. G't-Mei 1 t i")') f� C J l
Non-Water Supply Well: - l i
ft. ft.
❑Monitoring ❑Recovery -_
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) •
FROM TO MATERIAL I, EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier H. It.
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color.hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return]) (❑Other(explain under#21 Remarks) / H. r it, f'l1 j��C „ chi:*
4.Date Well(s)Completed:_ ')L` d(Well ID# E'�- ft. pi� ft. Jt yani L,
5a.Well Location: �Ll411. �l3ft. t itz
I lot�t.� (Yc I!e v•LLC- 710_/it Aar7sft. aUGfr(nu e
it. it.
Facility/Ownerity Name ��A Facility ID#(if applicable) ft. II.
Oto ik 1.a-•I"z ft. ft. - , r -: i._ :.
Physical
jAddress,
/ y,,anndd Z//iip� 21.REMARKS -- 2[ 2021
E' )L? cEo n hr'. ,i
County Parcel identification No.(PiN) : 77.1.'.'44747 I Up*
ZY "r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: am
22.Certification.
(if well field,one Iat/long is sufficient) (/
•
CO / .(/V N r3- . q/. l (/ w / �'y /�l
Signal Certified Well Contractor Date
6.Is(are)the well(s): (Permanent or ❑Temporary By skin'tng this form. I hereby certifs.,that the well(s)was(were)constructed in accordance
witlf I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or J o copy of this record has been provided to the v.ell owner.
If this is a repair.fill oat known well construction information and explain the nature of the
repair under 4.21 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-crater supply wells ONLY with the same construction,you can
submit one lona s SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ��✓ (It.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ne0s list all depths i/dierent(example-3(g1200'and 2@I001 construction to the following:
10.Static water level below top of casing: LOv (ft.) Division of Water Quality,information Processing Unit,
If water level is above casing.tar"+.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Lk 1 D (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
�i- L above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: / f�1 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) /0( Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
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 OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

Waft priliar Ste'-eront Cartification
Owner: - Vt Newt Well:_-----._
Address: R4Pair".• -.-..17.......-.. ...............^.----_____._--
Permit; 't3
I hereby certify'that
the above referenced well vow grouted in appearance in accordance with
all County Well mles.
Welt miller-
Construction: trout
Total Depth:- Type: 0479 I-
Casing Type: p UC Thickness:_ maid
Ong : S '__ `0. -
Diameter: 60,%I
volliOriT ---t,...----
Drive Shoe:
GPM: