GW1-2023-01182_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD Far Internal Use ONLY:
This farm®n be used fbr single or multiple wells
1.Well Contractor Information:
Josh Plemmons FROM FUOM
TO D&9CRiP170N
Well CnntrncletNnme
it. ft.
4137 A i
NC Well Cont aet9r Certification Number 1 O urn CASING veal ur oft EN m4aa Dabte
FROM TO DIAMETER THICKNPBS I MATERIAL
Clearwater Well Drilling Inc. ( ft. COO ItI U1131".
Company Name lidJNNER CORT[IBIA(i itnitllatetlltl=tie"'
FROM TO DIAMETER TBICICNBSS MA EIUAAL
2.Well Construction Permit#: v A�1 FL r` tn.
Listall applicable ivell construction permits(i.e.County,kate.)rartmtre,etc) ft, la
3.Well Use(check well use): 19 .Ent
Water Soppty Wen; FROM TO DTANMR I 3LOTSi7R I TIRCKNM I MATKR1AL
QAgricultural QMtmicipal/Pobllc
it. fL In.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 0' IL
flludastrial/Commercial ❑Residential Water Supply(shared) 1 BUT
FROM TO MATERIAL' Fb1PLACRMENTMUROD&AMOUNT
❑ltri lion ft
Non-Water Suppy Well: '
❑Monitoring oEffyer ft. ft
Injection Well: .,. '�s
❑Aquifer Recharge ,e—lk—s�—V undwater Remediation -I..9i PWORA . L'A f
I feCStO �t FROM TO �L MATESUAL aMACEWNTMrMGD
[]A
quifer rage and Reeovi DISavalatrier
d. i~
❑Aquifer Test JPy t]StGnnwat Dj'11
OExperimental Technology ``1`` R. R.
SIStt�;stdence Control
❑Geothermal(Closed Lung) F_' ' : lit. 11111 LOG ad i , i nm w
�niv� r�\l1 Tt�cCr FROM TO RRBCRIP(!ON color.1Wnhw nW=kr1mgraDa_far
❑Geothermal(HeatinjWCooligg Retum) 130ther(explain under#21 Remarks
4.Date Wells)Completed: Well ID#
IL ft.
5A.Well Locatio`r- ` R R�
Facility/t)w Name ``-- Faeilityll)#(ifopplicabie)
rL
1 I�r dl R.
Physical Address,City,and zip ITV 31 r G
Co Patccl Identification No.(PIN
5b.Latitude and Longitude in degreea/minutealsecamis or decimal degrees: C �:
(if well field,one lat/lon22.
g is aufficietd)
blab .©tZZ
�/ Si ofCertified Wall Contractor Date
6.Is(are)the weR(s}:�Permanent or ❑Temporary sig.riag ibis join,1 hcrol v certify that A0 arll(s)was(WM)rottvtnxW in accordance
'�\` r M h 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Cott mmflon Standards and that a
7.Is this a repair to an edsting well: dyes or p► ropy of ibis record bar been provided to the mull onmer.
ljtbtis Is a trpatr,fill out known well construction Information au lain the nahne ofthe
repair under#21 remarltssection or on the back afthisfotm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
&Number of wells contracted: construction-derails. You may also attach additional pages ifnecessary.
For multiple injection or nnn-amterstgrply xrgs ynu can ONLi with theaame consraction,
submironejornr. SIIBMIITAL INSTUCPIONS
9 Tota1 wdl depth below land surface: (R) 242. For All Wells: Submit this form within 30 days of completion of well
For tmthlple tvelis 1is1 all depths ljdkjf anent(ermnp/e•3r�200'mud 2Ga 100� construction to the following:
10.Static water level below top of casing: (M) Division of Water Quality,information processing Unit,
1f water level is above caring,rae"+`" 1617 Mail Service Center,Raleigh,NC 27699-1617
� B7 L Borehole diameter. (in.) 24b.Fir iniecfion Wells: In addition to seeding the form to the address in 24a
/�
above, also submit a copy of this form within 30 days of completion of well
12 Well construction method:__ M to YA I construction to the following:
(i.e,auger,rotary,cable,direct push,etc.)
Division of Water Quality,Undergi ound Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service tenter,Raleigb,NC 27699-1636
13a.Yield(gpm) Method of test: 1 4 24e.For Water Supub&InlMflon Wells, 1n addition to sending the form to
the addresses)above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
i
Form GW-t North Carolina DepartmentofEnvironment and Natural Resources-Division of Water li
Qco ry Revised 1eo.2013

Well Driller Self-Drq"t C*rdfk*""
Neon►WeIl: _ �----
Owner.,-La �-oo
I hereby cexdfy
atth.e alMe refer'Mcea wel Mra grouted in appMaz'Qe in aanceVdth
all County Well ales,
J oS p�ummt�t��rn 5 Sign �-�---
WeIl Driller-
Certificate#: l 3
Construct tO n:
pS Type: WnrV1i
TOW De-Pklz: T bjC1mess- k
Casing lrype--q-�C-
Casing I)q3t'h:14 Wt
_ Diameter:
GPW: ----