GW1-2023-01082_Well Construction - GW1_20230126

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WEL CONSTRUCHON EECORD FatrmaaeluseONLY:
Uls gum can be wed- �
1.Well Contractor ittformatfoa
Josh Plemmons ;
Well CM1r�cterNsme
4137-A IlL I
NC Weil ConnWorCettifiCalonNpmber t M TO Q gAML7all" l70CIt MATtlR1AL
Clearwater Well Drilling Inc.
Cmmquay Name 1'6'IBIl+IEI!'
n /��f{ IRtOfll TO MA7fR1AL
z.Well Cen.am
Ctinn permit 6: t�Dai it. 7
tn.
Lhtall apphatbk wail conttnu7lon patnits(l Ge ae V etc)
ft.
3..Wdl Uae(dtech VM0 as*. IT. [L'i( ItU► L
waters pptq we>i: 11ROM 32 afflam Too
• OAgriauhurat pMmticipeVPnbflo � >G fa.
l3G-hermnt esidential Water single) R'(Eletrting/Co�oling�PP$9 �PPIS'
IL
Dhdourial/Com olere a) uResidentiai Water SUPPly(shored) t
A RjATMAL EN ArPHINT1111110MIAMUM
Dirti lion IL
Non Wolter Supply Well. tr, IL
CiMonitoring OReeovery e
i t:ctitut tell:
OAgr»fer Rexhstrge Ll[iroundalttet'Roraediation
OAquifbr Storage and Recovery []Salinity Barrier To Ik. �' MttliWt)
DAquitct'Test QStotmwator Drahmge iL iL
13Bgm imental Technology 13SubgWence Control
Gaeodtermel(Claud Loop) 07'rne" FROM IEN "amm awn* ate
DGeothermel(HgftWQwft Regan OOdter lain mtder#2l Rt maths d' .S i%r I�Cam/
4.Date Weil(g)CompDbed: Wen 1Dlf
Sa.Wdl Locatinn: 'Pogo -f'l�u-S a� 2i'd
r� e
L3IL r !-
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Feeilhy naNttmi Padiityl�i(ifttpplieY►le) �. , �...a ty Ian�./
Lf 4 f cc flier t2a►, eAndle r ke tti JA N 2 6Phrkal Address,Chy,[[and Zip 21: nn
��fn�0 s74, 22 (/b XN3 f; in#t;;tt�a`a�� �r.��ssrst 7 Un,'j
Cab Palrxl Identification No.(PiN) J d u'
Sb.Latitude and Luq tmb to degmu/mtouteNaeconds or deeh=l degrees: 22.Ctyrttllaa
(ifwall field,an latllong is snf icekmt)
oa5 33 N �L.; , '9 _W ,.,
Sign fCertlffedWeHConIn=r h Date
6.Is(are)tote well(&):XPerouamt or DTetoporary By s j Ong this fotm.I hftadry-no that tl a xrA(s)was(taa+e)cmatrtt W/n"Co M"W
with SA IYCAC 02C.0100 or 15A NCAC 02C.02M Well Cmumxdw Stardarda mod that a
7.Is olds a repair to an etdsdng well: i]Yes or ,�6 rnpy olrhtr reand harbartprovidEd ro the ndl otrrrer.
Ifthm h o^r�ofe,fllimulb+own well aantrrmion li#hrmatlan and explain the nartve oflhe
repair rmdsr>f2/resorgtRs yytgt oron dre Aact r jihlrfiAm 23.Site diapmm or additbnai well debtthe
You may use the back of this page to provide additional well site details or well
8 Numbererwens tffiaelrueted• ( constmction•detail% You may also attach tdditiond pages If noway.
FarmaWple 40Wm,arnam--wersa"Iy we&OKIF wUh the some Wn—o-eNon,ymi can
submitnaefbrm. SUBWWffAL iNSTUC"ONS
9.T91111 well depth below land surracc:- / `7'S ((-) 24a.For All Well/: Submit to w1h Astall de this prin Within 30 days of completion of well
For muh lP prhsljd�'erertt(awmple-3(r�200'and2(oj100� wnstntcHnntothefol)owing: ,
10.Statte water level below top of caeiog: (ft.)
YHOW kw/kt Dlvhbn of Water Q 1617 Mao SeMee a/ay 4ClHy;IafermaHoa ltrotxtthg UNt,
alxrve oosi�are�+�/ G 0*RAMgA,NC 2709.1617
I I,Borehole diameter. 24b.Far Inteetien Wens: In addition to sending the fans to the address in 24a
above,aim suta dt a copy of this�fbnn within 30 days of completion of welt
12.Wen eoagtrnedonmeth&-• conetnuAlonto the foDaw,ng:
(i.e.RIMv,rotary,cable,dirtet ptah.eta) --
Division of Water Quality,Uodaground Injection Control Progrrtm,
[FOR WATERSUPPLY WELLS ONLY: 16M Mail Service Center,Ratolgb NC 276994636
.Yield(grim) 3 Med"of test _ 24e f'WaterSunoly&lnieetlori R►ellae hl addition to sending the farm to
theaddresses)above, also submit:one CM of this form Within 30 days of
Dhlafleefton type: Amount. calup1glion of Wr1(eonsbllctioo 101
0 the county health departmettt of the county
where cansicucred
Form(3W.t North Carolina DRmtumtofEnvironment and Nntumi Remmem-Division of Watertjaelily Revised Jim,2013
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