WI0100727_Geothermal Well Construction Record_20240620

WELL CONSTRtJCT1ON RECORD
This Rbrm can he used fir single or multiple -lb
1. Well Contractor lahrmatke:
Josh Plemmons
F'or Internal Use ONLY;
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4137-A
NC Well Contractor CmtiBcationNumber
Clearwater Well Drilling Inc.
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Company Name
2. Well Construction Pt:rtnit #. �~ v. "`-' ""
List oU ayplicabk wsll cowatrvcrtar ppmI& a, Covwty, Stara. Ya•k—. ele.)
3. Well Use (declt well use):
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ClAg cultural ❑Municip l/PubNa
(Heaiinog Cooling Supply) ❑Residential Water Supply (single)
C3kxkwtri&V ommemial ❑Residential Water Stipp ly(shared)
O"1119tion
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MATERIAL
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OMonitoting ORecovery
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❑Aquifer Recharge DGroundwater Renediation
13Aquifer Storage and Reommy OSalinity Barrier
OAquifer Test ❑Stntmwater Drainage
OEatperime nml Technology OSubsidence Control
OGeothermal (Closed Loop) O'Praeer
OGoothamai Ram) OOther er lain und#21 Remarks
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ss. Well LsctNialt:
Faeitity/Oiraer i-im�e r. * -t-.-,Facility ID# (if applicable)
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Car.ity Pucci Identification No. (PIN)
21. REMAstris
Slkk Ladbode ad LAgg tm3e in tleRt easitattt oxen/aeeMdrr or dec11u1 degrees: FAAACACC
:(traaroE field, am bdloag is.11
Wall CoMraaror °
& 4 (si * aft warus): asrmW or ❑Temiwnry . I herop cere that the we#M waswer}caarrsrnedC .0100 or MA NCAC 02C -aM A'a11 COMO R'Me! SOaMli01� a t rase7.1a t1Yk a rrepair /e tm exist ft watt OVea rM as m brew provided to roe well owwrr.
r�iepaW A Mwa►kr sea M Or � rZf thtr ffiM, a�rhr 23, Ma diagram or additional well details:
�� You may use the back of this page to provide additional wall silo dowils or well
IL hlantbar arasaYtr t:anatracklo consuwotion details. You may also attach additional pa8eia iftteeees ity.
Far a akwe 1 or tWrwoaar WVOY ,Idle ONLY with As slaws ataaatCAW^ Y'M rgas 9l)BMtTTAI INSTUCTlONR
nriwatt am fall.
9. Total waU depth blow land surfaces Itt j 24a. jjLAjVj&s Submit this form within 30 days of complauatt of well
For muko to (w anoe- 3�Ij2P#'sad 2�100) COMMUGUOM to the fwk)wtug;
Ill, Static wow level blow tap of ratline: (ft.) Dlvieia: of Water Quality, latbrmadon Proetlsai" Unit,
Uroaw I#sd tr above 080AW we "I " i 617 MW 'Service Csoter, Raiei&h, NC 17699.1611
11. Barebde dlanaaer: (la.) 2& for laistgn Walls: In addition to sending the form to the address in 24a
ahoy,, also &Amit a copy of this form widtin 30 days of completion of well
12. WOO edtmorsedon method: t:o►sbWdon to tM following:
Ox- -wr, mealy, able, dire: Polk eta
iNvklaat of Watts' Quality, Underground Ityectiast Caatwl P»gratq
PM WATER XUPPLV WELLS ONLY: 16M Mail Service Ceater, Rakigb, NC 27GW16M
13a. Vivid (Vm) Medsod of its 24t. ft Suilmh & Inlaotlon Wella: In addition to sanding the form to
the addrw*es) above, also submit one copy of this form within 30 days of
13b. DWnfeetka type: Amount, completion of well wnaftWion to the county health department of the c"
where constructed.
Perm aW-1 Norm Carolina of .—A ►r..,_I