GW1-2023-01158_Well Construction - GW1_20230126

WELL CONSTRUCTION RECORD rFor Tatennt Ilse ONLY:
This form can be wed for single or multiple wcTts L
i,Well Contracter Informatlen:
Josh Plemmons To D68CRIl7tOTt
Well C tt. n
Contractor Name
4137-A
1 7MA
NC watt ContnaWgr CeRitkatton Number H M To OtAaRTgtl 171lCItIVi88 LClearwater Well Drilling Inc. '
Corntmny Name td. �
HkOM Tf) 1➢IAIMRTRR MATNiiAL
2.Well Construt'tiott Permit#: �- A. ra.
Lixr all appbeahk well conatraeNon perniils(l.e.Counly.Stale.Yariamv.e1cJ N —
3.Well Use(check well use): iq• —
waler 3m�ly WON: FROM To DIA sa or slzc tlllcic MA IAL
ClAgriaultural OlytssticipaUPublic _
Ot3eotheretal(Heathrg/Cooling Supply) residential Water Supply(single) D I
L 1116
OlndoarrieUCommerciai 011esidential Water Supply(shared) mI MATMAL tent A AMOUNT
❑Irri tion 1
Nea-Water Sappily Well: J
n. e.
[Monitoring ORecovery _.
lid eetMn WeIP A. a
❑Aquifer Recharge DGroundwster Remediation =1Ploll_
C)Aquifer Stomp and Recovery ElSalinity Battier t.4 salrir�❑Aquifer Test fMStormwater Drainage
OE:perimental Technology OSubsidence Control
t :
OCieothermal(Clotted Loop) OTracer jL=rtft
aID skDGeothermal a oolin Rein OOther lain under#21 Remarks �-) �1— y
4.date We"(t)Completed; I O Au Well lD# UT-1 � tiff
O � �
AL
Sa.Wen LocMkeq:
It
Faeility/OwnerName Neelliky1DR(ifap ankle)
Phgwal Addrer,City �
N G
� 21,
County Parcel identification No.(PiN)
Sb.Latitude and Longitude in degreWminutes/seconds or decimal degrees: 22.Certl
(if well field,Otte]at/[on g 11 sufficient) t
Si ofCdtitiel Well Conaa clor bat
6.Is(are)the wewzy: anent or Mewperary 9' - thi.,farm.1 hereAv ea*toot the xr11(.,)we,,(wtem)camnvered In acmulitrwx
'' `` A'Vft
CAC 02C.0100 or ISA NCAC 01'C.0200 Well Cantfne rkX S Nwvdr and that a
7.is this a repair to on existing weH: DVes or a twin the narnrc o/the
repair wider p21 re"amjx sc llon or on Abe hmk of this farm. 23. iagram or additional well details:
You use the back of this page to provide additional Well site details or well
tL Number of wells constructed: amondetails. You may also attach additional pages ifwry.
For"aldple Gr jaetlrm or non water supply wells tN L P with the saw eenmrWOOw,ymj can
xuA/Mtonefi-inn. SUBAL INSTUCTIONS
9.TsU11 Well depth below land stWf*M: 13 l i� tit) 2AIL .AI( WNI� Submit this form within 30 daW of completion of well
Far"#triple wells lilt alldepth.,irdoerwl(.ww#c-3(a}200•and2@100) conson to the following:
14L Static water level below Mpofcasing: (ft,) Division of Water Quality,infornudn Pnse aft LWt.
(f#»ter level 11 ohnve casing,tce"+" 1617 Mail Servcee Cmder,Raleigh,NC 176�1b17
11.Borehole diameter: (Its) 24b. lnlectien Wells: In addition to sending the form to the address in 24a
abovosubmit a copy of this tbrm within 30 days of completion of well
12.Well construction method: \ 1 `, t C V\-,1 ennFn to the following:
(i.e,sager,rosary,cable,diroet push,eta} of Water_
FOR WATER S IMvhbn 16M Mall Service Center,Raleigh,ergirstand NC 2a769 46%Control r�n�
SUPPLY WELLS ONLY:
13a.:1.1
d(gpm) Method of test 24e.F�W�&RR v&laiaedon t tldditlOn to sending the form to
the_addresses) above, also submit one: copy of this form within 30 days of
131L itel sfectlon type- Amount: completion of well construction to the county health department of the county
where constructed.
Form GW.1 North Carolina Tkpartment of Envirooment and Nnturat Resowees-Division of Water-- -- - QuslitS'