WI0100721_Well Construction Record_20240523

1 • Well Contractor lorot•mtttion:
Josh Plemmons
Well Contractor Name
4137-A
NC Well Cor rector Cerlifcuion Number
Clearmter Well Drilling Inc.
Company Name 7' •�
2. Well camtroctioo Pernik M:
Lint all fW'Cable well catefruction permia 0A CMMr K SYMe, Vark nm. rM )
3. Well Use (ebeck well use):
Agricultural
OMunicipal/Public
(HoatinglCooling Supply) OResidential Water Supply (single)
Olndustrial coon etcial OResidential Water Supply (shared)
Non -Water Supply Well:
CiAquifer RechaW
OGroundwater Remediation
OAquifer Storage and Recovery OSalinity Barrier
OAgaifer Test OStormwater Drainage
OEaperimeutal Technology OSubsidence Control
OGeothermal (Closed Loop) OTracer
4. beft VIVell(a) (ouvleted:
Well IDR
under1121
Facitityr0"M Ideate Facility [D# (ifapplicable)
Pbyacal AddreW (ft3; and Zip
Cowry Parcel I&Mification No. (P)N)
Sb. La*ir mW Iwngkude M Aegreeslmianks(secon& or decimal degrees:
(ff W811 faald, ace MVIO g is sur5cimry
6. Is (or* doe a11114): J'eneaeewt or OTau" ry
9. Its dole a aRlld' AD ON *d6 tg WAR: ❑Yes or P60
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21, RBMARKS
22. Certificatiow
�L _ S" 3 -.37
Sigoalum Cenified Well Cmwwwr Due
by nigat " Mix fW t ) k WAY cere'jj• leer aloe + OBW aro eAWW aXUVW d ae ancae„t MM
with 13A NCAC VC .Ol fb or I S.r .VCAC AZC .WW fled Coate wc&w 3leadw%* and Jut s
cwy of thin rtv wd hen bean prvvkkd Ao Ar welt owner.
33. Site diagram or additlexal well details:
You may use the back of this page to provide additional well site delude or wall
coastmtiou details. You may also stewed additional pages if aoecss"V.
SUEMITTAL INSTUC13ONS
9. Tet/d aNfdl ta}l�lb balitlw halt/ sthl#aaas: fit.) Ha. VK AM Mesa Submit this fittm wl" 30 drys of COOWleticu of we"
trer.wdripis aandr law aN /ev+ia 1f s�ar (�raP�+ il(�i ' aa'I 2 16t0) "Msuuetion to dw folkwiug:
I& Btattr water I&M bdow No adtwdwV (ft)
40rwo r kwof M 060M 4006% awe '+'
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12. Well ow ate w an dw L,
(i o. NNW, salary, addr, &naa rusk 00
ItOR WATZA surmY WEI" ONLYI
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MV6480 of Water Quality, Qalnaaaw hulaawg Uw^
I617Mill swvkoCeaw, RSM06 NC?Ttiwl"7
21ib6war j"go .1� h! ma sddithu sortdwg qua ftrm to oho addma in 24a
above, aka wbwdt a copy of qua farm wabin 30 days of now k*M of wall
eprao uguee to dw fpliuwiv*
1liris "of water Quills, Ifrrdwgtasati IuJ� �1°'
16M "a t "Aca Cameo, lbllefA*
lle. adtition to seadiag dw ft- to
tbo addraM(as) WM alao wbarh on, copy of Ibis ftem within 30 days of
warp daa of well ctawer mtka to the as ay health depsrtmmt of ft courts'
rinse conantnaL
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toluene cNal as Dayawoars arewAaa mw aal wood ROWAM - ohisk a orwalu Qsa'w
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