GW1-2023-01106_Well Construction - GW1_20230126

wLIJ CONSTRUCTION RTCORD For lawmal Use ONLY:
Thin form can be uxed fir single or multiple wells
1.Weil Contractor Infarmotlom:
Josh Plemmons Bali m t ON
Well Contreder Womb
ft
4137-A °
i G 1
NC Well Commolor Cortifim. ion Number M 7Y1 Tyg t "REKNERS I MIATEML
Clearwater Well Drilling Inc. L tUe,
Campeny Name *�t ', tfi 7N1L7nifaS MATRQAL
2.well Conduction Permit NJ� + l�`i't� � r. � L h%
List all applimlik"it cowtnw1on pmWzv p.e.Couro.Slate Yana=NO IL in.
3.Well Ilse(check wen ore): to
waterseqMW& rtloat 4o D A A7ER L
><. n OAgrienituta! OMtmici]wUPtrbnc � ft.
DG-theratel(H-duglCooling Supply) residential water apply(single)
OlndestriellComnercial tesidential Water&Pply(shared) TO iIA L AKouHr
13kri tion B () IL `
WA
Non venter Supptr wen: n, IL
�Matitoring DReaovery
laJeetlan Welk fl. R
OAgnifer Rwimrge 4:lGMundW4w Remtedietion 1 .
OAquifer Storage and Recovery OSalinity Barrier tro MA tet►rttwe n
n. a
OAquiferTest OStormwaterDrainsge
DExpedatagel Technology ❑Subsidemx Control
13Gcodte psi(Closed Loop) OTracer FR M 10p OrM Y ■litrart
OGeadlennel a. Coo Realm OOther LaMIMn lmda#I i Remarks n' B' 1��
R092
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4.Date Wen(a)Completede Wtellift era A
rr.
So.Wen I.oclltian: 2�Z l.f t✓V i 1 dcr 5
e'r
i B. (L ji
Feo►li►Y/ Name F'acilityn)ti(ifapplieehle) a,
P neat Address,City,and Zip 21:
II
Cry 11%eel l uffimtion No.(PIN) j'fn`ccFr�3«,� t�f��4iu v� 'n;'
5b.Lotitade and Longttode to degmsiminntealwanda or deelntal degrees:
Ofwall fetid,an latllong b sufficient) /�� '22'Clit( '
U�j�.�..,.� N l J() ° �Jvi �� bd W --- .�--
jpr�
oMertlnedwelicaw ever Date
6.is(are)the well(s)t vent or t7'1•emporary A&j�,r.I hm+etiv-n*rhw die-nfs)wo(seen)cnuitat�cted fa aeovAix ee
CAC 02C.0f00 or!SA NCAC 02C.0200 Well Com a ten Stleltfmdt told rhtif A7.Is this ra m air to an wrie ft well: ❑Ves or istr rrrnrd haslarar pmvtded ro r)x erl)owner.
ljthk L*a+epotajtl/mnlbrewa mrll c»nsttuetlon!@lbrtnatlnnand explain the mama-e ojthe
repair radar q21 tenranlasedlon oro»the Mrk ojrliiojnrm Zx sm madram or addidend well detallie
you rosy use the back of this page to prmride addifiotml well Hite deWls or well
8.Number oftestisconstructed: comtructitm-deiails. You may also atlechadditional pages ifneccasary.
Farm OP&b9 Won orrmn-wale mMlywe&OAMV n4th dre same consrruet100%ism$car
aulanitmreform. SUOM3Ti'TAL INSTUCTiONS
9
up TOM Well depth below land surface: s fR) 24a. For AL Wells: Submit this fitrin within 30 bays of txmlptttiarr of well
FarMUDWc-)b list all depthsIy4t-,u (awVc-3@2DD'aad2QlOD) eoranuctiaato the fo)lowiag:
i l
I&static water level below top of c"og: (M) Division of Wire'Qu1Hy,lefornttdttta pracesllag ilttl�
ynester kvrl La An*cmnA.we,"+n° 1617 Mail ftwlcr Center Wtlalgh,NC 27W4617
11.Boreiole diameter. 1� ..(in.) 24b.For Infection NsW In additionito sending the form to the add=&in 24a
�^ above,also suhnnt a copy of this forth
within 30 days of completion of well
12.Wen conotrnetion method: Tim(, I_T! constructlon to the following:
(i.e.aa�r,rotary,cable,direct push.ern.)
Divlslon of Water Quality,Undelimund injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ceoteir,RaMgb,NC 27PA4636
13a.Yield(gpm) U Mu d of tea6 24L For Witten'Supply&lWado►,ells; In addition to sending the fmm to
the addrrss(es)above,also submit one copy of this form within 30 days of
13h.Dklnfeetlan type: Amount- completion of well construction to the county health depwUneat of the county
Where const[ugtod.
Formt3W_1 NmthCamllmDBPattmentOMvironmentmA?4atamtResomcea.-DivbionofWaterQ liry Revbedlen.M3

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Well Drlll�r say-Great c.rtifiOfflonf
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•Zc�zo
Owner:
New
-WeIl:
Address: OO
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I herebY cexdf'y that the abM refemred well ChM,grouted in appearanw iin accordanoe vdM
i
all Counter Well rules,
Well Tariller: p5
Sip, c.-c
Date:�G
Grr��C:
constlucdorr f
i
el
Wig, M Tbidmess.
]Deps... J -,
Casing, = 1th.
Diameter:___0 1
vveigntjxhick:_—,--
Height
Drive Shoe:
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