GW1-2023-01113_Well Construction - GW1_20230126

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WELL CONSTRUCTION RECORD Far T,ttdml Uno ONLY:
'thin firm can be wed for Single or multiple wells
1.Well Contractor Infarmattoo: 14 A
Josh Plemmons
onf To
wen Ctrgr.elortv.me- R. ft { I
4137-A
NC Well ComrnotorCaftationNum1w M aAliQ7ZU � a
Clearwater Well Drilling Inc. "' a"\
(�j 1i6.11dlt&R MA'i'QiTAL
Coenpanyxntete I.t � m
ft.
2.Well Construction Penult 0: I tt to.
L&tall grMwble well emeraWan permlte(l.e.Cotetry,Stole Yarlancv;elc) p, ta.
3.W'MUae(dwelt%wous t7 s= MA lAL
IRtDat
Witten Sespply WeV:
ClAgriestluttal 13MmilchialftbUc IL 1te
13Gcothetmal(Hmthtg/Cooling Supply) esidential Water Supply(single)
oTndastriaUCmtmnaeid EResidential Water Supply Owed) 1 � ro A ,L a
Cllrtl tton n
IL
WwWa w Wdl: ft.
OManitoring ORecovery 0. Q
la,)edlan ell: -
ElAquifer Reebarge L1(3rottndaater Rturtediation M zo trA u
t]Aquife r Sttnage ail Recovery Emr !ty lit 1. A. tt.
❑AgniferTest E1StonMMcrVRd1'lee n.
ORxpmdn=tel Teefioology pgnbsidence Control
130coftrmal(Ginned[.00p) OTraeor FRMoN�-p M .tivrnak n
oGendiennat(Hmd*CooHilg Rmn aOBter )ainmiler#21 Remarks
�7� M IL ca p
d.Date Wel(s)Completed: _1"7 Wen IDl1 f& al. y
5 wen I.oeatlan: f+ IL `( ; 1
u' Mt
FsellityJ Name FeellGylDO(ifapplieshte) n,
Physical Addrear,Chy�andZip 2L'
I Mdl_� SDCI
Cmmty PmcalldentitiaatianNo.tPINI ' y
5b.Latitude and 1"Otude in degree/pdantcs/secartdin or deeloal degrees: TWO
(ifwell field,one Minna to aufficieat) p , i
414 wedwdi arm6.la(Ilse)the 1Fe1!(t): fMh�msnett f)1 Crlefti�>tla1S1 m,1\\ c.0100 or 15A NGIC 02C.0100 Well Comtnt�r."&Mdlads a+ld flwt et
I In this a repdr to an exkdng well. Oyes airAl may nfrhis ltxrrrd hm hem pmvlded ro the tern oamer.
Ijihls leor�otr,finanrbrowrt weAmnanucrron Il[�rmarion and e�lain the n�mme oalhe ''
rrpafr urdel•all nmgtAsaeet/onoronthahaed•oflhlpJarm. 23.3Ite diagram or adtHtienst well dewila:
Yml may use the hank of this page to ptmeldt:additional sell MM deaeib or well
&Number of wept:constructad• oonstruction-deWIL you may",attach tettditional pages if necess try.
Formulrlplea#calm ON1YwIlht/resmneoonatracNae YOU Unt SAIHMIfT ALINSTUGTiONB '
MATHona,�rm.
9 TSUI well depth bdtew laud surface:_ (Q O J [(t) �a F9r All Wens: Submit this farm Within 30 days of Cmupw n of well
For!rump*%W)b its,all depthslfdVffam(mmmV&3Wt►a-and2woff) constnrtaitmto the foll01VISW
10.Static welter keel beioW top of txtdng: (ft,) Division of Water Qaft,Infarntadon Prawsleg Unit.
If water level Ll alxme cult', 1617 Mao SllVtee�i t2r,Rl♦181g11,NC 27 -1617
11.BotteYMe dlanteter• l a I (tn.) 24b.For In jil o N&W: in addition to sending the form to the address in 24a above,also submit a copy of this forms within 30 days of completion of well
12.Well conahuuetlan meowd: MA S"__ aonatniction to the following:
(i e.auger,misty,cable,dire dpuab,eta) t U mid I ecOn Conftd
IltvUlan of Water Qrlallty, .ndergto Rl Progrtttnt
FOR WATER t3tIPpLY WELLS ONLY: }n/ / 1636 Mali Service Center,Raleigh,NC 27699-1636
13a.Yield(gam) Method of test:. 1v�1 2&&K wa VA&&IRlt n�Wellg: M adtition to settling the fame to
the addre*cs)above, also submit one copy of this fmm Within 30 days of
t36 fllsinfedlen type: Amount- completion of Wdl construction to cmtaty health dMmtttmnt of the county
witene Constructed.
Form t3W-I North Carolina DepaetnwettofEnviremenent and Nntatat ism nreae-Division ofwaterQtiality Re*edJan.2013

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'W ell prliler self-�m"t Cerl�fleatien
,
owner, -
Addrtm
P2S dr.
•Z-ZjO c)\D v\l�
I Iner&y aex*that the above�i od well tnr�grouted in appeax'an� ` 0 °e with
all ComtyWeR rules
•
well D dRer: J �\n Y Si 'rnrned' LIC�77 -- L
^Grou
Certificate#: ��� 1t�ad:
Construction: '
Total De
LaOS5 Type: �n can n &
Casing,fie: Tl�irlmess: (`�
Casing Deptt: W O Depth.'
Diametex:��\S____--
WeightJThiclf;., --
3�eig�:
Drive Shoe:
GPM:
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