GW1--04912_Well Construction - GW1_20240816

G
WELL CONSTRUCTION RECORD
This form can he used for single or multiple wells For Internal Use ONLY:
1.Well Contractor information:
Josh Plemmons 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name R. ft.
4137-A ft. n
NC Well Contractor Certification Number is.OUTER CASING(for multi-cased wena)-OR LINER(if applicable)
PROM TO DIAMETER THICKNESS _ MATERIAL
Clearwater Well Drilling Inc. / n, -Ell' ft' fetn. v6
Company Name � IG INNER CASING OR TUBING(geothermal closed-loop) `�
��2, 00451.(a4.2
f y1 1,r� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Of ✓ (1(/(i-�t/Y: r ft. fL in.
List all applicable well construction permits fle.Cushy:Shale,Variance.etc.)
ft. ft. lit
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public n• ft. la.
❑Geothermal(Heating/Cooling Supply) I `t.esidential Water Supply(single) n n, in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT =_
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT❑Irrigation /
ft F1 IL /
Non-Water Supply Well: v�L' , e/� / /77L
r //p C 7
❑Monitoring ❑Recov eTY ft ft.
injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicabl�JFROM '
DAquifer Storage and Recovery OSalinity Barrier ro MATERIAL EMPLACEMENT METHOD
it. n.
DAquifer Test ❑Stonnwater Drainage
ft. ft.Technology OSubsidence Control
20.DRILLING LOG(attach additional sheets if aeeeasary)OGeothermal(Closed Loop) ❑Tracer
FROM TO DESCRIPTION was,berdaen,m tVesck type,hale site,etc.)
❑Geothermal(Heating/Cooling-7RetunA ❑Other(explain under#21 Remarks) ft' t1Q ft. / 1����` ?L
4.Date Well(s)Completed: l—15-2 A Weil iD#. C 1�/fin "- a ILr�,r'd�_'i n
Si.WellLocation: l StC li L Z1( ~ i L _r �„(-9
(7C('�7 h Win drop ` ft. ,�3 . '. aAA/-e'
R. is
Facility/Owner Name Facility iD#(if applicable) v
074 tS/n�� ,4 a /7 _ H. It. .
� jp/7/) ,,r fir. �� ��
Physical Address,City,an Zi ft. R' i. 1 Y
p 21.REMARKS "1 1 I
6)r)CU/77/. - 4U6 1 e 2024
Cow Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degreesinhsutes/seconds or decimal degrees: )f : »t 'f" t���r ' Unit
22.Certi on:
(if field.one lat/long is sufficient)
/ r'G�. 0-3N ,F tc5 " O ._3 v., anr,r
S' ofCerified Well Contractor Date
6.Is(are)the we9(a):JKPermanent or ❑Temporary
.signing this form. 1 hereby certify that the well(s)was(were)constructed in accordance
'di 15A NCAC 02C.0100 or 15A NCAC 0.'C.0200 Well Construction Standards and that a
7.is this a repair to an existingwell: ❑Yes or JO. copy of this record has been provided to the tell owner.
(/this is a repair,fill out known well construction information and explain the nature of the
repair wider#21 renarks 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,vnn con
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: .3 ! (rt.) 24a. For An Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdJi erent(example-3®200' nd 2@100') construction to the following:
/
10.Static water level below top of casing: ( V (ft.) Division of Water Quality,information Processing Unit,
If water level is above casing,use"+• 1617 Mail Service Center,Raleigh,NC 27699-1617
iG
11.Borehole diameter: (.()/J (in.) 24b. For Injection Wells: in addition to sending the form to the address in 24a
1�'(2 L above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: r77 lf 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 Mail Service Center,Raleigh,NC 27699-1636
i/f( ' 24c,For Water Supolh&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) /G) Method of test: /
t the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount:
where constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

VMS Delft SeiIlMariat Cordneadon
joPisiie &C('
owner-j±al-eia .
dsor • Newweik
Addlemc Repair . n•••• •.••••• •••••
Paint (2,23
hereby cextifythat ibe above referenced well was grouted in appearance Inacconlimondth
all County Wen rules.
Well Dam /Yu Y,'' L-7,-j - -
C.seildeeto: '- Date41,6114,7
Ccestructiona Grout
Ibtel Deptft Typr,..—e-dnegi
Caging l'rec,
Casing Depth: 8l.fi DePtil- e26
Diametr:
Drive Show,
GlIk, 7'