GW1--03703_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 OESCRIPTIOr
Well Contractor Name R. R.
4137-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for mold-cued sills)OR LINER(if a ikable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. ` rt. ) fL U )7 in. ";<-_
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
� (( l! �}U. FROM TO DIAMETER THICKNESS MATERIAL
r
2.Weil Construction Permit It: 1(:. -,)r. .� - i 151 R. ft. 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
ft. ft. in.
❑Agricultural OMunicipaUPublic
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. a. in.
OlndustrialCommercial ❑Residential Water Supply(shared) Is.GROUT _
FROM TO MATERIAL .* $F1 .,Acidnipir METHOD&AMOUNT"MAT
❑Irrigation it.
Non-Water Supply Well:
`�� "``' Oi m,'�^'
ft. ft.
❑Monitoring ❑Recovery _
Injection Well: ft. U.
❑Aquifer Recharge OGroundwater Remediation 19.SANDIGRAYRL PACK(If applicable)
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIALEMPLACEMENT METHOD
R. R.
OAquifer Test OStotmwater Drainage tt. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if aenwry).
❑Geothermal(Closed Loop) OTracer FROM TO DESCRiPTION(color,bantams,Mlltrack type,grata size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under ii21 Remarks) , ft. ‘...\._j ft. l a c , t'+
43 n. ?mil l(r ft. (N( i}C 1.
4.Date Well(a)Completed: Well MU /I
5a.Well Location: 317)3149 R. - 11 U.
` 2 d.1 L(
K)1 1\(cL\T i i V k' Q\SU ft. �lj ttS et. a��,;u
Facility/Owner Name Facility 1DM(if applicable) 'w� ?- -
C ire .IN 1 A*c . Rd ft, tt. 'gyp' v
Physical Michas,City,and Zip 21.REMARKS JUN_1 8 2024 .
1-' .rc\e1c i _
County Parcel Identification No.(PiN)
-, DIhCp h;,wi
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificatf :
(if well field,one IaUlong is sufficient) C
•_) a 4: ,3.J. I !tC N .' _
Sig fCertified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By sing this form.1 hereby certify that the hell(s)was(were)constructed in accordance
with SA 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 ANo copy of this record has been provided to the well sinner.
If this is a repair,fell out known well construction Information and etplain the nature of the
repair under fill remarks section ar on the bock 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 con
submit one form. SUBMITTAL INSTUCTIONS
rl�
9.Total well depth below land surface: L�i l.r D ((t.) 24e. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(=ample-3®200'and 2E l00') construction to the following:
10.Static water level below top of casing: QU (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing.use"+" \( 1617 Mail Service Center,Raleigh,NC 27699-1617
U t
11.Borehole diameter: ) (in.) 24b.For inieetlop 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: i ( r Lt‘, i\ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: (: S
24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) J Method of test: 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 G W-i North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

= lS atoa
itulgeD
�Ir t) SulseD
:gloa
oima
taw,aoueprom ui paanal sem nem paoisaajai artage mit °&wattI
1:31 - , - Sit