GW1--03653_Well Construction - GW1_20240618

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information:
Josh Plemmons 14.WATER ZONES i.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4137-A ft. R.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-eased wells)OR LINER(if ap livable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. l it. q 3 ft �c;'\ `itt.
Company Name 16.INNER CASING OR TURiNG(gee thermal closed-loop) �^)U
0 ,� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: \i\i S d n. it. In.
List all applicable well construction permits(i.e_County.State,Variance,etc.) R. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO . DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑MunicipallPublic ft, It. in.
❑Geothermal(Heating/Cooling Supply) j2f(tesidential Water Supply(single) ft. R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) S.GROUT
�FROA1 TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
['Irrigation i ft. c9k.' ft. (ik 'i\Alia 1v1 1 Y_ (C I
Non-Water Supply Well: it. R
❑Monitoring ❑Recovery
Injection Well: ft, ft.
❑Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEM ENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. tL
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidenee Control 20.DRILLING LOG(attach additional sheets It necessary)
DGeolhermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,bardaess,sail/rock hype,grain size,etc.)
DGeothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) 11 R• Ci J rt. &i -1 `1-- CIA' -
4.Date Well(s)Completed: Well ID# �l 3 ft. 'an ft r(A 1Lt f�
Ai\eric S Hus--) �\ac� ?� IS' R. C J�►(�1
tSaj Well Location: (� C1 31r a. ` l 'l15 ft. c•.yak f • . f
l_tir..i )n(L y' V'e ic> C /{c J R. `t Ot it. , a`L.e 0... : V E[r
Facility/Owner Name Facility iD#(if applicable)
-�- ' C/ ft_ ft. '1 IN 1 8 2024
I ) �.:1 d Li C '� J C It, n•
Physical Address,City,and Zip 21.REMARKS It kv...d...:.1,3"""tit:7.; Jp,
I ro.t-\ V IVC1 .ruCt �M"°fit'`=
County Parcel Identification No.(PIN)
/1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificati
(if well field,one tat/long is sufficient)
Signature o ertified Well Contractor Date
6.is(are)the well(s): 7Permanent or ❑Temporary By sign g this form.1 hereby certify that the well(s)was(were)constructed in accordance
with 15)4 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 piVo copy of this record has been provided to toe cell antler.
If this is a repair,fill out known well construction Information and esplain the nature of the
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
B.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 farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 'T a .) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iifdderent(eramp/e-3@200'and 2(p)100') construction to the following:
10.Static water level below top of casing: ('L' (ft.) Division of Water Quality,Information Processing Unit,
If water level is above easing,use"+• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LQ ) (in.) 24b. For Injection Wells: In addr:ion to sending the form to the address in 24a
l above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: (C.) I Cyr I 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 Malt Service Center,Raleigh,NC 2169 9-1 63 6
• l ,`�
13a.Yield(gpm) , �Z Method of test: 4`)C` 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 GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

Wall Meer Saii-ertoat c.,dt ►
Aryt ,r i cas k-mp in CI
New Well: -
Qv'nier —_----
Addres
v.�pd3 �1
I bereby certify-that the above referenced wen was wonted in appearana:in aroxrdttnce with
all Comity Well rules.
wel Driller,
certi sate : 4\31 -/4 Dote atinted:,___.,.
Cow/make: Clout
Total Dgpth: . L4as Type:-
Casing
Thickness: r c�
3Caging Delith: =— aD
Diameter: '.►7
Weght rsc.._-Y----
m
Dive Shoe:
GPM: '1 2r . _