GW1--04916_Well Construction - GW1_20240816

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This firm can be used for single or multiple wells
1.Well Contractor Information:
Josh Plemmons 14.WATER ZONES
FROM TO DESCRIPTION
Weil Contractor Name ft. fL
4137-A ft. ft.
NC Well Contractor Certification Number AS.OUTER CASING(for metltl-eased wells)OR LINER(If etp able)
ROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. i it. , It. Li,;://'�-* in. pt,t1
Company Name IL INNER CASING OR TUBING(geothermal closed-loop)
/� / FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 19 L'L1 3 C�Of �! ft R. in.
List all applicable well construction permits(.e.County.State,Variance,ele.) ft. ft. in.
3.Well Use(check well use): 17 SCREEN Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
DAgricultural ❑Municipal/Public
DGeothermal(Heating/Cooling Supply) Residential Water Supply ft. It. in.
( g g PP y) � pp y(single}
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S'GROUT
FROM TO MATERIAL q EMPLACEMENT METHOD&AMOUNT
❑Irrigation / ft' .,f� ft. (/J,1 l n/4- 67
Non-Water Supply Well: ft. ft.
OMonitoring DRecovery —
injection Well: h. n.
DAquifer Recharge ❑Groundwater Remediation I, 19.SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
1 ft. ft
DAquifer Test OStonnwater Drainage ft. it. -
❑Experimental Technology ❑Subsidence Control 26.DRILLING LOG(attach additional Nimbi if accessary)
OGeothermal(Closed Loop) OTracer FROM To DESCRIPTION(solar,hardens,sorvreck type,grain size,etc.)
OGeothetmal(Heating/Cooling Return) Dether(explain under#21 Remarks) / ft. ) it. 2 ✓ ? nL di'r/-
�} Liu ft. jI y ft. "-a/Li/Le4.Date Wells)Completed: ��0Nell 1D#
/14/ ILN'Cr- ft. UGP/ e
5a.Well Location: II I�ft. /(l S ft. CiI��CU!"c
ail ii/C��ts LCG •
�,...• ii .J
Facility/Owner Name _Facility lD#(if applicable) O. O. AUG a
2^24
„ Ip 14A i 41e.. a As-IkA it/E ft. ft.
Phyff 1 Ad City,and Zip 21.REMARKS •4,fli9R.f A r# ,. .,,1 1 jai
J L)1) Ci`7)/9 DA cesC„
County Parcel Identification No.(PTN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification'
(if well field,one lat/long is sufficient)
� ` j21) < �t/t N (2' VS"' 93. t. 5W % 4.---y' ,, 7,ac ,)-c/
Signature of i ell Contractor Date
6 Is(are)the well(s): [ ermanent or ❑Temporen By signing thi rm. I hereby cent,that the nell(s)was(were)constructed in accordance
with 15A NC 02C.0100 or 1 SR NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: DYes or k'No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information an explain the nature of the
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.
Far rnnbiple injection or non-water supply wells ONLY with the same construction,you can
.titbtnhl one forms. ����)) SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 11,c5 (ft.) 24s_ For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdl,¢erent(example-3(4200'and2@J00') construction to the following:
casing: `
10.Static water level below top of T//rJ (ft.) Division of Water Quality,information Processing Unit,
If water level is above casing.use"1-," 1617 Mail Service Center,Raleigh,NC 27699-1617
// /F
11.Borehole diameter: /0 J U (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
L/�JI ) l� , above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: / (J l��L�i`f! 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
13a.Yield(gpm) 0 Method of test: Aci 24c.For Water Sulu*&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-I North Carolina Denanment of Environment .. . •. --.-

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