GW1-2023-01156_Well Construction - GW1_20230126

RECORD rrorta�t useol�IY
'I as farm can be used for single ar mutdpto rrdls
L Well Contimctor information.-
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Clearwater Well Drilling, Inc. Hof Springs, NC 28743 I R R nimx�� � THrcrma>ss"
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injection Well: R
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❑AquiferTest t7S IL $
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Sb:Latitude and Longitude in degr'ees/m'tnmtes/s:conds or decimal degrees
Gall e d.o L l ng is suf&�=) / 1 2L CertiB[afion:
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5t_ ofCem ed Well Contmetor Date
G.Is(are)the we11(s):�I ermm-ent or ❑a eatnarary
Bc sfpdng tlrts farm.1 Gurby eErlbe dirt the uellfs)um(u ar)cmutraued hr acwrdance
�is a )club 13A NCAC 02C_0100 or IBA NCAI-02C.0200 IV-7 Consmrctian Srmulords and than a
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Pair to an erisftag well: Over or�o copy oJtldr rrrntd lras been proaldrd ro tie urll mraer If t(ds Er a repah:JV► l.IIDa71 rre11 cmtrtructlon Inforvmum,and erplain the ttaatre ofthe
rrpan•rmdarg2l ranmrdT sectlan or on the bacloftlasfomc 23.Site diagram or additional well details
You may use the back-of this page to provide additional well site details or Well
G,rmultiple nImaoOtwe s constructed- t:oastruction details_ You may also attueh additional pages ifneeessary"
Formaltlple Injection or mat-ltntersrrppl3'ur1Lc ONZY7ettl/the soma eonrtraa80A.3aa can
submitonafarm SIJBDfflTALi7YS UC3TONS
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9.Total well depth below land surface: ✓ `/`/�G�✓ IR) 249. For All Fydls Submit this form within 30 days of completion of v'eU
Por mublpla 1re11s fist will dep&#�tdJ imnl(—plc-3®2001-d 2@100) construCtion to thefoliorving
10.Static water level below top of Wig; (fr) Bivisiaa of Water Resources,information ProcessingUnitljuarerlceef is abort car/rr�ate -- 161714Yaif Service C+:mter,Raleigh,NC 276994617
IL Borehole diameter: ft) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
a Well construction method:.- 24a above,also submit a copy of this fora widtin 30 days of completion of well
construction to the fallowinX
(Le-auger,awry,cable,direct push.cue,}
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY-,*VEU S ONLY 1636 Mail Service Omter,Ralelgb,NC 27699-1636
3a_Yield(Wm) Method of tesC `� 24c.For Water SanD(c IniectroEl Wells
Also submit one copy of this form within 30 days of completion of
13b.DkinfecdontjTm Amount MR construction to the county health department of the county where
const ucted-
Foan GtY-1 North Camlina
IkParaaeatofEa'uaamentaadAFattualRcwacees-DevisionofNaterResc+uQaes RevisedAlteust2013