GW1-2023-02040_Well Construction - GW1_20230303

WELL CONSTRUCTION RECORD rrfnresnaluae ONLY:
Ibis form can be teed for single or multiple wells
1.Well Contractor information: IIa WA'17
Josh Plemmons _km TO UMCRIP'ION
Well Contractor Name• �._fl. - f
4137-A P •
NC Well ContreotorCertification Number t [i
M ' TO Di , ER MOB ATRAIAL
Clearwater Well Drilling Inc. or. at. k 1! in. - \„eel
Company Name //�/_ 7 TO DIAL sun 11110 N 8 MATERIAL
2.Well Con:action Permit#: 2•O✓O r 0t? O. ln.
UmalI appHrnble well construction permits(Le.County.Stale.Yarlanee,eta) — O. p in. I
• .
3.Well Use(check well tie): 17.11011311121warn*I wants riterammi miasma
To
.—Water apply Welk ' 'ft. ft]
U.
OAgrieulanel ObtonicipelPubUC
O(ieothermnl Heitht ool Su Residential Water Supply(single) ft' -
( 13� �B Supply) lei.�'
DindnlarialConunc cial °Residential Water Supply(shared) ARniN TO aTmai. CWNQNT a.Asfinut T
D1nRation J R- 0 It. ` 1'�1-l+ �� t Isi
Noll-Water Supply Well: -a. A.
I]Monitoring °Recovery .
lideetlenWell:
°Aquifer Recharge C1t3rauntitvate Remetiiation , 1R03 '� }r' o 11 rma aL ammAcaterxrMiriam •
t]Aquifbr Storage end Recovery °Salinity Barrier a. a.
°Aquifer Test °Stoimwatu Drainage P.
°Experimental Technology OSabsidenre Control #D. • 1,,r .,, r : ltjf yj' .
OGeaherm al(Closed Loop) DTracer PROM a as oia/ sdrnektyea,Urals tsq els)
OGeatbermal(Heating/Cooling RetUn I]OBter(explain under#21 Remittita) \ it.
, ft.
I l�ti _
4.Date Well(s)Completed: i a-1-r Well IDS b 30 Z". IS,
Sa.; EvkLthgyWel�l Location: p t. 339"• lik l �
or-nos
Facility! Name Facility IDfl(if applicable) ft.
B, Ir.:v ''2,y Fy: 4 ,a q�-
P. :esl Address,City,and Zip .21: MAR n
h� M� � Identification No. ,l�f.:�.11:�:i�� i J•i.
Coy Primal taentit (PM)
Sb.Latitude and Longitude in degreeshninuteeleeconde or decimal degrees: 22. _ , ; den: 1
(if well field,one laUlong Ls sufficient) :
O i �t3.1UN0sa��a5L.a W /i,, -. ' - -
Sig of Certified Weil Contractor Date
6,Is(are)the well(s): Permitnent or °'ftmporaty B..signing slits form.1 hardv cert*that the tell(s)was(tens)constructed fa accordance
mth ISA NCAC OZC.0100 or ISA NCAC 02C.0209 Well CoAslrurllon Stenda Brand that a
7.Is this A repair to an existing well: °Yea or io copy of this recant has hear provided to the wall owner.
!phis,is a ropatr.fill ant know well oonstruetlon htfrmatfat.anti esptaln the nature of the �.Ske diagram or additional well details:
under N21 rarsgrRsseationor on the back ojdtlsjarm.
You may use the back of this page to provide additional well site details or well
&Number of wells constructed: conduction details.You May also attach additional psges'ifnecessary.
For multiple fr nenen.vaawmjy4r ills ONLY with the netrneltnr,you can SUB IT LAL iN9TULTiQN9
submit one Awn. 33
9.Total well depth below land surface: (tt) 2Aa.Fir AI Wells: Submit this farm within 30 days of completion of well
For multiple wells list on depths ldtfe„enr(ample-3@,200'rmd2@l00) constnictlon to the foilowing
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
(boater level N above caving,tee"+°1 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: W ` _ ( Q) 24b.For filiation Wells: in addition to sending 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: constnxxIon to the following:
(i.e.auger,rotary,cable,direct push,der) Whim of Water Quiity,Underground Injection Control Program,
FOR WATER SUPPY Method of test: 1 WELLS ONLY: �A.�ij 24e for W 1636 Mail Service Center,Raleigh,NC 27699-1636
20S nD &IfLe d011 WARS. 10 addition to sending the form to
13a.Yield(gpm) the address(es)above,also milimit one copy of this fotm within 30 days of
13b.Disinfection Amount completion of well construction to the county health department of the county
where constructed. ,
i
From OW-1 North Carolina lXee.ir...nt of Environment and Monet Reeoumea—Division of Water Quality Revised Jan.21)13