GW1--03696_Well Construction - GW1_20240618

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 R. ft.
4137-A It. R.
-
NC Well Contractor Certification Number IS.OUTER CASING(fpr tnultl-eased we)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS _ MATERIAL J
Clearwater Well Drilling Inc. I rt. li. ft' i f,`' in. _) \'.r
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. R. Ia.
Lisa all applicable well construction permits(i.e Counry,State.Variance.etc.)
ft. ft. In.
3.Well Use(cheek well use): 17.SCREEN •
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
°Agricultural ❑Municipal/Public ft. R. In.
°Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) i 18.GROUT
FROM TO MATEi IAL- EMPLACEMENT METHOD&AMOUNT
Obligation ' R. r ( n, cCi 1 1C.1�'�/�f r� 11
Non-Water Supply Well: ft. ft.
� I } i(�
°Monitoring °Recovery
Injection Well: ft. ft.
❑Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK(if appucablj
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery °Salinity Barrier - -
rt. R.
❑Aquifer Test ❑Stormwater Drainage ft. -
❑Experimental Technology dSubsiderrce Control 20.DRILLING LOG(attach additional sheets if necessary)
°Geothermal(Closed Loop) °Tracer FROM I TO DESCRIPTION(color,hardness,milimek type,arab sic,etc.)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) fL I8 fit /fi `.- cle i•(-
4.Date Well(s)Completed: Well(D# �� ��� Ira,
t1 �.i
5a.Well Location: \Il R 1. m !e Loc o \S/f. WQ�SR' 9ra,nite
r 1)co n .c- L_L.Cd. (L .
Facility/Owner Name Facility ID#(if applicable)
-
3rl 1 \ThS-"1_f'. XLfl . R. ft.'
Phgjjical Address,City,and Zip 21.REMARKS .1`:'c- 14
Ial C1C..0MY Wait a Tvesco..,r tJri
County Parcel Identification No.(PIN) D'cacia • ,
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.C
(if well field,one isulong is sufficient)
Signature" etti ell Contractor Date
6.Is(are)the well(s): rernianent or °Temporary By sign this form,i hereby certify that the well(s)wxrs(acre)constructed in accordance
with 1 NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: °Yes or klgo copy of this record has been provided to the well owner.
If this is a repair,fill ow brow»well construction information and explain the nature of the
repair under#2I 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,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: L-A. d. J (R.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3L1a200'and 20!),/001 construction to the following:
10.Static water level below top of casing: (C(- ' (fl) Division of Water Quality,Information Processing Unit,
If gofer level is above caring.use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �( I (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: rOtar VI construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) •
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELL$ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) t Method of test: tL I Ci 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 Driller Sali.Dirout Cordficadon
owner: - .,r, (�rF n l 1 .. NewVel�` -------__._----
Iberthy omtifytbat the above referenced well was grouted in appecc'ancein .. t, , ,-wall
all County Well ram.
Well Driller_ Leh _ 5 =
Date el , -
Construction: Grout
Total Depth: ' Type C'A Casing
TYPe: P.v TM.rlcness: N". 'Au d
Casing Depth: �$ :__
Diameter: l� 1
Height:
Drive shoe:
GPM: a