GW1-2023-01147_Well Construction - GW1_20230126

I
WXJ .CONMECI'IUN RECORD For Tnternai Use ONLY:
Thin form can be reed for single or multiple wells
1.Well Contracmr Itdanmatloo: A
Josh Plemmons Ol TO
ft
Weil CenlraeterFleme•
4137-AMA
_ l
NC Weil CommotorCcrilfi4ation Narl M TO fi pait►aT THIS L
Clearwater Well Drilling ins "' ftto
CompetryNnttb ]p[Oss TO >Nl►D1lRRAIn. 7HiCQ1ia8S 10AitAOAL
2.Well Counrecdon Palreoit*
LW 411 aR*=hte wd1 wmWucdon permftr(49.County.Shale,lrarlmme.e!c) p. H. M.
3 Wdl iCLc(eirekwell oaejw
92Q CKMA
Wrtas'Supply Wes: Z- ,n—
(L �;
OAgrieulttnal pMtnticipallPttbt)c13Gcothermel(HeetfnglCoofiog Supply) !]Residential WaterSupply(single)
(3111d tstrinucar ardal ORcddaltial Water Supply(Shared)Olrti lion R
Non Water Stlppajl Well:
OMatitorfng ORerovery tt
Jejectiall
OAquifer Recharge Q(boundwtttcr Remediation 1 •
FROM
m
❑Aquifer Storage and Recovery OSalinity,Barrier p, fL
13AquWer Test pStottllvvnter thairtage
DEttperimetnal Technology 13Suhsideitee Control
DGeothermal(Closed Loop) 0 racer Toorl Y talvnrt ate.
OGeo3 oral ffeatiq#Caoft Rtdlna QOt)ter fainunder#21 Reloads t n' k'
11
of
r� rn} \
0.Date Welts)Cotnpllekds -p(q/�oC Well iD# a.
ILa tq,
5a.Welt i.ocatlaa: ^ p p. �. r"16..7
n ` �
('- . 1re� v�e�, is n n. 2 ZaL3
Faeility/OtvtterName Pacilityll>if(ifepPlicable)
K� �Cc�� 1'�C., 1�\t 1c� nQ n
l A ip City,and
K
C—ly 1'51x1 men61ieotion No.(Phil)
Sb.Ltantude and LoaggUude is degreWmteutWkwands or decimal degrees_ ;22.Veadfkjk
(ifwell field,one iatnong is sutficb;n) , tdWeIIC rMctor Dale
6.la(are)the well(s):`�Pernaneot or 137emparary Br airp fug Lbws fowm.1 M*Av mO thaw the Kr0(s)xros(one}conraveted in aeooadmtcr
With 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 WHI CottrlrtrCM&aOsTm'tJr and dW a
7.lit this.a repair toaneMagwellt f]Yes or 00 cnpYoflhtvrcrnrdhmhearP,nvl f►oihenrlioatru.
Ijthrs>s o rupatnJlllmttlbtmv»tvr11 merfiucwton!►llbmxrtlon and explain the wrcmor ojlhe �.�dim or addltiaaal wall dtdaUa
repatr rmdsr w12t row arlisaralon oro»tlia lKmtolthrs fwm• You may use the back of"page to provide edditimAl well site delaits Or soli
e.Natnbet-otwetla contrncted: constmction details. You may els0 attach additional pegm if itecel ly.
Farmuhlplelryar�lanornonwnrersyyrlywe!)sONLY�vllhthe+Y9+eoanlhaclhra yis+cmr n
suhnthnne,prrnr. � BUHMtITAL INSTliG"17ON3 !�
9 Ttgal Lea �� 24, Far Ail Wells: Submit this fort within 30 days of completial of well
For Muhlple xr� domft jd/ff�c-3@=�''mrds®roa) ( ) mnsntVtion to the followinw. �.
10.Static Crater level below top of eA ft.,^.�.Q (ft) Dlvidon Gil r Qaft.information Pracndag UOK
rue er laud It&howewhr,me + 1617 Man*jMeaClellr,RaMtg><,NC 27MI617
1 !'
11.Hord ola dlamt ter.LO .,,(in.) 24h.Ear jnj2Sft We,IN: in addition to sending&e form to the address in 24a
above,also submit a espy of this than within 30 days of completion of welt
12.Well coustractlen mow:
construction to the follats4ng
(i.e.anger,rotary,cable,daeetpush,eta) plvplon of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1ti36 MeU Setvt�Center,Ralal$h,NC 276941696
13a.Yield(gpm) Method ofteet: 24C ft Wa QQWb&itl_itirdto t wells 1n 9MitiM to satding the far to
the addra*cs)above, also submit one cW of this fam Within 30 Clays of
13b.DMnill type: Amount Complt'hon of well coMtntction to the county ht:glth dopat inm of the carry
where constructed.
Form GW l Nonb Carolina Depertmentof Environment and Natural Resnwrea-Division of Water"ity Revised Jan.2013