GW1--03697_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
FROM TO DESCRIPTION
Well Contractor Name H. ft.
4137-A ft. fL
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wills)OR LINER(if a able)
PROM TO DIAMETER THICKNESS MATERIAL
�
Clearwater Well Drilling Inc. IL DO ft. ,` In. `CVO
Company Name 16.INNER CASINO OR TUBING(geothermal dosed400
/�O .4 r�,n,^ FROM Tq DIAMETER THICKNESS MATERIAL
2.Well Construction Permit ft: a U U ft. iL trr.
List all applicable well construction permits(i.e_County,State,Variance,etc.) _ ,
n. ft. In.
3.Well Use(check well use): 17.SCREEN _
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS - MATERIAL
❑Agricultural ❑MunicipalPublic rt. n. In — —
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) n, rt. in.�—
❑lndustrial/Commercial °Residential Water Supply(shared) l&GROUT
FROM TO MATERIAL _ EMi'LACEMENT METHOD&AMOUNT
❑irrigation ' It c© n. /1/I C1(1/J 1(' rnl i/n o
Non-Water Supply Well: it ft l K a t tat tX X
❑Monitoring °Recovery
Injection Well ft. R.
°Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of apaileabte)
FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Storage and Recovery DSalinity Barrier ft R. — , --I
°Aquifer Test ❑Stotmwater Drainage ft. D.
❑Experimental Technology C]Snbsidence Control 20.DRILLING LOG(attach additlCaal sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DFSCRIPITON ccolor,lea saiVroek
( � ,-f rdaatt type,grate sift etc.)
°Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) f n. l V) ft. J J t ci(y-
4.Date Well(s)Comp ed:5`Z4 Weil(D# L �'�"DR. ",- ra '( i
1 . n. Q ft v t ( Q
5a,Well Loeati0n:,_--_ n `lS t�fu. `e L Jk-X "r i i
ft. EL ^'
Facility/Owner Name Facility Ma(if applicable) ft. ft. f s 1 8 28?4
1`P,rRbl La. lei a rC C0 n. R
P i al Address.City.and Zip ) .tM'1>#ffS4�/rti'irj;URiX .r
��I V-)C, 31.REMARKS VIWLI�Gfj
t Vui il l
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certific on: —
(if well field,one bUlong is sufficient)
t D .t9' (0 N ) 41 rj. :�-1 w _ 5- 3 -c)(
Si ofCefified Well Contractor Date
6.Is(are)the well(s): Perrttaneot or °Temporary signing this form,I hereby certify that the well(s)nos(were)constructed in accordance
with ISA 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 no copy of this record has been provided to the r.ell owner.
lfthis is a repair,fill out known well construction information and explain the nature ofthe
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 infection or non-water supply wills ONLY with the same construction,you can
.submit one farm. G SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: `0 p S (ft.) 24a. For Al Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifdierent(example-3@200'and 4}1001 construction to the following:
10.Static water level below top of casing: (D V (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: .S0 1 v (in.) 24b.For Infection Welts: 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: 1r O.1 /, 1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I •
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLYzWELLS ONLY: 1636 Mall Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) Method of test: V�ci 24c.For Water Supply&infection 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.20I3

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+ all t°widthways
tom:_ Newv�.
OiDLDOOStA
I hereby certify that the above referenced wet VMS grouted in appearance inaxardanoewith
all County wIlni-
wen Driller::TOS1-) P\escmd\s /4_____-
carfare#; 4 -4 Dalet. , S-
Construction: Groot
Total lQ 'ram. - d
Casing Type pVC. Thidmenc n c,1
Deper_ 026 _
LQ
Height
Drive%Lim
GPM