GW1-2023-01149_Well Construction - GW1_20230126

FsL�L CONSTRUCTION RECORD Far Uttmt d Use ONLY: 4
Timis fmm can be used for single or muldPle wells
1.WdlContmetorludormatlon
OSgCRIPTI
,Josh Plemmons om TO f
f.
p►ell(`ruatrecter Name
4137•A � R
c
NC Well CoMmetor Ccrd t*ton Nomber M To 1l1AtlBTRiI i TMCK M ?AATBBUL
IL
Clearwater Well Drilling Inc. In.
ComM
_ 16.7IIllb"X T�Nggy MA4m1tAL
i Nium Cttnttd uctlop Pts'tnit tF: �[- — 2- erne[ a TO2.Well a n1Aiw>zT�><tn.
1&1,W1 applicable well comiructlon permf&{/.a Cotmry.Stale-Yarlaxas elcJ f` t1, �•
-I-Well Use(awekwon am)- A g� N^T=mL
Wauer Sapply We>i: moat !L !s•
QAgrianhutai pMrutriripallPabtic 1a,
Mlatnharnzd(HeatinglCooling Supply) Atesidential Wear SUPPIy(single)
[]1tldassitiaueomtntaeLll ❑Residtxttial Water Snppiy(ahstu d) NORM"— BEAMliar wAMouar
❑lrrl tian rK
Nor[Waar So"Wdfi �.
❑Monitoring ORewvery (L
l.Jredop eu:
13Aquifer Recharge - LI&Md=ter Remedietion
p(tO1t TO MA > 1<11/r1 At.'Rh�Nr
OAqui&T Storage and Recovery OSalinity Barrier IL fL
❑Aquifer Test laStora water Dr aiwe p, B.
Olsxperimetrtel Technology G1Subsidcoce Coattnl
130codiemtal(awed ia*) 137mer RZKOOMON � �� R
OGeotlia'rlriai earl lin Return [lt)dw lainunder#21 Remarks R' n' Y
0.Darr Wdt(s)Coulplead: Well ID# I I�P = 1LC
So.WeB Loead f4 '
Facility! erne FeeilitylDtl(if Irenb ) p,
. IL
P)�@icatA Cl%andZip
COVIL
C�wrmly Parcel ldentifieatien No.(PIN) j
5b.Lm tnde and I.ottgttade in degrtcestltdnuttst/seaonds or dedmal degrees: ?M'715�A
�fd,ane latliong lls suffle1 nt) Zz
�(' .� (� ( �r j�
ofCauIfledWellCenRactor 1i DM
6.Is(are)the u mKz): PliOUtU'ffi or [ITesuporm [htc form.i hff&N'W*tha the we11(aj tuns(xmr}Voin qrw fa accordance
NCAC 02C.01W or!SA NCACOZC.0200 Well COMOMfm Sstrldardr and that A
T.Is thle re rspatr to an ertistlng wc11: Oyes or o rnny ofthLr mord hasbem prootdedro lie'wdl owner:
fOrIttbargW1r jfllontkmffltt*dlWWmctlon lrllbmnalonon erplatnthe MffcOfthe
nepatr wader A21 rrmgrAssaetton oran the hackofthtr firm. 23.S&dlagtam or add1donal Wdl details:
Yost may use the back of this page,to provide additional Well tote deans or Well
&Niumberofwdkcanurneted: onnsterction•details. You mayahio�atta bXVltionalpegesifnaxsaary.
Barmul[lple brjenlon cremt-wa�xupphrwM ONLYwllh[lreaxsterattshucNen,y'W= !'
aahmltonefirm. (� syBmrffALINSTUCTIONS i.
9 Teml vacs depth bellow 11and sgalhw. 101 �J ?Aa, Fo�4n warts: Submit thi I farm within 30 days of completion of well
FartrruGlpletue depths d1(fetent(argmpfo- t10'mtd2®10o� (�) CorNtntcdm+tothefollowing:
In addition?Ab.Fo
IL Static vfaaur lcwel bt laW top of cash: (OD (B•) Division of Water QOality,Inform flan Ift"O 8 Unit;
Ywater level tr ahem a ra lam we^+• f (i j�� 1617 Man 3lli+lee Cltitr<i,Rakipb,NC 27b99�1617
tatrteat: v (In.) For WOs: i
11.BoT*We d to sending rho form[[to the adthen in 24a
above,also submit a copy of this form within 30 days of compbttion of well
12.Well constracdonmetitod: � ` /t constmetiontothefbllowing:
V.e.augur,minty,cab*dheetpu,sh.eto.)
Divbion of Water Qaaitly,Uatteeground 1njettion Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mao Servlm Center,Raltiigb,NC 27699.16%
13a,Yterd(gpm) Method of t �n 24�R°r W Stioo v&INIGa n Wells: M addition to sending the farm to
�----- the Address(es)above, also submit one copy of this faro Within 30 days of
13h.DBbfaetlon type: Amount: Ctiniplotion of well constnrction i the county health depeitmtnit of the county
whcte wnNi acted.
Form GW.1 Nnnb Carolina Dep mnentofEnvironment wx!Natural Itesomm-Division of WaterQnility Revised Jan.2013