GW1--04967_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD —
This form can be used for single or multiple wells for internal Use ONLY:
I.Weil Contractor Ilsfonnation:
Josh Plemmons -1(4.WATER ZONES
Well Contractor Name ...FROM TO DESCRIPTION
ft. ft.
4137-A _ ft. ft.
NC Well Contractor Certification Number 71.OUTER CASING(for multi-caved*vile)
OR LINER Of IleaMe)
PROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc.
Lc �I in.
Company Name ft. ) ft. ��
16,INNER CASING OR TUBING(geothermal closed-loop)
\\ (1��_ t� Q PROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: r(/ V O ft. ft. la
Lill all applicable well construction permits(1 e.County,State.Variance.etc.) M t
ft, fL In.�
3.Well Use(check well use): ,
t1 SCREEN
Water Supply Well: PROM TO DIAMETER SLOT SIM THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. IL la
DGeothermal(Heating/Cooling Supply) fy4;;tesidential Water Supply(single) H. R. in
❑industrial/Commercial ❑Residential Water Supply(shared) iGRo1JT
Olm tion PB.ROM TO /MATfEERIIArL EMPLACEMENT METHOD&AMOUNT
Non-Water Suppl Well: I R• c?( it. l.
' _p.1 t f Y0' 1 'I�_1 S�(rl
❑Monitoring °Recovery ft. II.
liklectlon Well: ft. R. ~
['Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable
°Aquifer Storage and Recovery °Salinity Barrier FROM TO j MAT¢RiAL EMPLACEMENTMETNOR
❑Aquifer Test ❑S R' R• 1
tonnwater Drainage _._
❑Experimental Technology ft. ft,8Y °Subsidence Control
°Geothermal(Closed Loop) 17Tracer 24.DRILLING LOG(attack aural sheets if aweessary)
PIko f TO DESCRIPTION(allot,baednuus,asnhsek type,grain ruse,etc.)
❑Geothermal(Heating/Cooling''Return) LiOther(explain under#21 Remarks) l R• ;a I• SxI cI cI k( t
4.Date Well(s)Completed: ui- oi i) - )lWeil 1D# ��l/(�n� R �y R• �(� p `e L T
5a.Well Location: 5(04)ft' 510� ft. 3 U Ji_ t
L urIn1 c : fin. '- : C t >°
��?��C�C'Cn..CI C�.i'I(;Q,I' it, ft.
Pacility/OwnerNarrre i t1 13 Facility IMF
t� ft. ft.
` Y i�: �[.f./ILY. 0r. ft. ft.
Physical Address,City,and Zip
21_REMARKS ALIIj I ,. nn
\ Ztt1`,vf I i(; Y c C;
County Parcel Identification No.(PiN) -' ir, r . ;yam'
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: / O
(if well field,ate let/long is sufficient) • 22,Cet dtka tS t/
?. TSaSIc14-.1G Sty' Lva ( )ci .gib �..
N qm /- 3— (/
Signs( ofCertifie'd Well Contractor Date
6.is(are)the well(a): 4ermanent or OTemporary
stgnhlg this form. I hereby certify that the well(s)was(were)constructed in accordance
ritdr ISA NCAC 02C.0100 or 1.A NCWC 02C.0200 Well Construction Standards and that a
7.is this a repair to an exists well: ❑Yea or kNo
ng copy of this record haw been provided to the well owner.
If this is a repair,.f/i ant known well construction information and estdoin the»attire of the
repair under hip remarks section or on the hack of:Micro). 23,Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple lnjecttotr or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMiTTAL INSTUCTIONS
9.Total well depth below land surface: Ll2 4 5 (IL) 24e. For All Wells: Submit this form within 30 days of completion of well
For multiple wells ltst all depths if different(example-3®200'and 2®1001 constr Uction to the following:
10.Static water level below top of casing: (DV (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"1-'' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:
U (in•) 24b.For lniectton Wells: In addition to sending the form to the address in 24a
12.Well construction method: I� ��ti above, also submit a copy of this form within 30 days of completion of welt
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
•
I3a.Yield(gpm) J Method of teat: L-i -i 24c.For Water Sanely&Jnieetion Wells: ip addition to sending the form to
the address(ea) 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 Department of Environment and Nanual Resources-Division of Water Quality ty Revised Jan.20113

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zIlinby Cestifythat dh Agave relierenced well.watt grouted in apperealce,In accordance wi►
all Comity nies.
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UlDiameter:, L0.'
Drive Shoe
GPM: 5