GW1-2023-02150_Well Construction - GW1_20230306

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WELL commu,crioN RECORD
F Tata arstUeoQr1LY:
This Ram lathe tried tbralMle ormidlipk vial
1.Wdl Contractor Inform l olo
Josh Plemmons ,t
.TD,.. skecittlAtaiy
WellCommelarName. R• ft. j
4137-A ft tz 1
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NC Well CofR QrcoitlfliationNpmber1.;;Fir.;:-.: .;I' r. ' . ',1.:*
is'_. ,1I4
Clearwater Well Driftingd R: Irt. f�X)C1
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comply Name Inc. 1 U. , _M .- 1 Ma'TIIRA1, ,
2,WdlevaillitctIonPetwot#1 R. L is..
LW ad OppBarbte we tcoeirataftn pemrtte(Le.County.State.Melte=eta) -.
3.Wdl Use(dwelt well rue): to ft. fa.
Wafer Sap*WIR: --- - --nmllltflt ,' thdirealt *Minn MAIRIdat.
ClAgrianitnral • CI
ft. Ja.
[7Geothennel(Heathg/COOlit8 Supply) Ale-Meatial Water ly(ainBie) ft h . tor'
Otadastrial/Cominerclal ElliesIdmttiel Water Supply(st(stand) pl`
a1M ire► aaAtM> ,..J. ... 't .I-;,:
sow►Wal: . k a-, � R,���`i(1 n-j-- fC`Mv..1
CIMeoftoting CIReeoway e. a.
Injection Welk A. R
OAgnifer Rectum alratmdwnta'&mediation Tgortaktommatu � ritroo
DAgtd(br Storage end Recovery ['Salinity Battler .
Wcr Tee ". M.
OAgu
G1Stromwaltw�Drainage
D drrm e Expe »ml T eltltoingyr 13SttbsWatae Control 1. R
Baca l(G7oadd Imp) Maur ?Ippie ImMttlu do.atra
DOeotttarrwl(lendng CSt ooti Remen) ClQdter(atplain under#21 Routh) 1 a LQ0 ti SOLIThCA 4- (k
4.I�ate WACOC.eplottat 10-�Z 7-W 1110 (f�[�'� o7F5 I °� Q('�'l�fl,l il
• Sa Wee Leamatm oa�ON*. 0 PS —
A IC5". ('I ll f 1 -e„,
i1�Q"I F1m1iUTh1M111erlJtaae Pbel{kylDll(ifatpplfatdtle) it. re. I, r'' .
•_' ,1 S rip. FS ,l, 4 . -
Physical
Cry Pamal tdmidfies iron Um(PRII
Sb.*Mute aid Langthee is dtgrsesleninntedaaeseda.r decimal degre:a• 23.(.'ed!<eatien:
Oi.
1 Ofwen field.one lading
a N (Na °SRloa.s W /,- -- /n 021 - 021J si,,. ,��..ofCettl fled WdlConttactar Date
6.le(tme)the w> 1)t YgtVrinaaett or I]'fenw.rary Ep', ilia Jarm,1 oot(&dad rite we11(a)trey pen*m penatem rted rh aeca woe
✓✓�� 1SA NCAC OZC.0100or ISA NCAC OW,020D Weil Cimeroalat&Ward;Werra
T.la this at repair to an es sting well: Ma i at k14a erlry ofaitrecordAtobear provided to Ole wen°exn',
ry'+Mre.oeepoe atribow»stet 1 commits rtylbtioattonandmktn1Ramrl+aeofthe
equip wider matr ,stye sko ar an do on&ef tan,(ar" 23.Rib Ammo oradriidast well atiWu
Ymi S.NumbesrOwe s aertraeled: • consun may
use t e heck of Oda pade In provide addItiontd n sits �awell
ondt:tells. You If
An'midge la+ornot-.ttatrsepplyvallr ONLY wig thenesuetnefwetle4 yen cart
DO ty
Well otiefbMt. l SU11MltITAL 1NSTUCAB ON
r.Tun wd1 depth NOM 1aiuA s : 4-0 (ft.) 24a.Fear AU Wain Submit ilia from within 30 days of completion of well
Par rteMpletaelio list oil WxRtif'd,6batd(arnmep►e-3(4)201r ford 2(100'1 omens tctiontothefellowlnp
I9 SOW water keel bags tap ofeling:' (a,) IIIVISlolt of Water Qt:sti(y.iafarmadla MeaarisII Unit
!tooter level it alma awn toe
st"+" i 1617 Ma8 Santee Caner, NC 276 •1617
It.anode d tinter: l 0 I QUO ?Ab.)For lnyetiae w in addition to Gentling the form to the address in 24a
above,also submit a copy of this form within 30 days of eompletin of well
12 well conarnedee stetted: t iT-E . ( eonstractlon to the!:Bowing:
(i.e.INIRM tnWq.aeh*ditectpno!►,eta) Iblvfelen of Water Qiudity,underground/heed's Control Program.
MR WATER SUPPLY(WELLS ONLY: L/� 1636 Map Service Center,italef b,NC 276+191636
13a.Ykld(elm) y- Mtdbod of tat:_ � t 2dc.Far Wa er Sonaly a.lsenan We➢n 1p addition to omitting the farm to
ounce)
�,�-�� �} doe addrrs$es)above, also submit one copy of this fmm Wiihia 30 days of
tab.Waialeale*it rper ({ f'j ni. Amonttt: o IL e) eompltdion of Well construction to the Canty health department of due amp
wham:conettucred.
Fern 1R►t Naito Carolina Depa tmentof Faevrromnenr met Neteaat Raeeaco,-ltvialon anther
Reviled Ian.2013

Well Driller 5elf-innut Certification
Ten
owner:.\\M 1 io 4- :V00.. _ . New Well:
Address 2qD01 C—br!e,`S ' ee pair:
Permit: 1 f1C, rS \ t 1 I,JL
I hereby certify that the above referenced well was grouted in appearance in accordance with
all County Well rules.
�►velt Driller_ GSh ROSITPW5 Signed:: /L.--------
Certificate#: LI-I �1 -A- Dart.Gro I D-1 `Z- Z Z
Construction: Grout
Total Depth; `O E ' per--ara k
Casing. ype: Thiclmess: IRS.
Casing Depth: O Depth: c4D
Diameter: l9 I
Weight/Thick:
Height:
Drive Shoe:
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