GW1-2021-03756_Well Construction - GW1_20210823

828-622-7241 P.l
Feb 1519 05:43p Clearwater Wall Drilling
WELL CON STRUC'CION gECORD lGW-11 e +� Fnr lntemni Use Only:
t 1 Cnntractor Informat(o -
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ZONES
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Well Cmttracta NaiveIL
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Campany Name 16.UVNER CASING tyR fU811VC *w" -1 eloaid4co
IRtO TO DtAMti"�R 771ICk1'tESS MAt{Ei11AL
2.1Ye11 Yt Construction Permit#: a. Ft In•
List ali olyriicable Ivey cmultuetioe permits(t.t%r/fC,Cormty,Stale.Variance,00
R. ft. in
3.NYrJt ilse(check well use)_
17.SCRBSN
Water SupplyIvell: PROM to DIAtltEthlt suorsae T9tctrnttss >,tATeauL
Agricultural 0'Mimicipal1pubtie () iR. it_ N
Geahcriv l(licating(Coding Supply) MResidential Water Supply(single) tk tL Jim
e T O aMAF[ndusirial/commercial [3RsidentawaterSupply(shared) 1&CR LMATE H D&AMUNTFIRMM
irrigation
:Yon-Water Supply Well:
A4alitoring Recovery
injection dl: fi• R'
Aquifer Recharge QGroundwatcrRemcdiation 19 Sp It
TO MATCBUL ��M t�
' aquifer Storage and Recoveryc3-Sstlittity Barrier M fL
Aquiti r TcR []Scmnwetcr Drainage
Experimental Tcclmology
Subsidence Control tti ft•
fences 20. RILU gGLOG attach alitatsiftteettea , r,h„iwac.
3GcOthernial
(Closed Loop) Peox To mtSCRIPrrOn eotar, ---t- w>1ltaaA
Geothermal(Hcatin ing Rctum) 0tber(ex in under#21 Rcmarl s) ft �l to / jG cSQ/1G� Cat
A.DaftWeli(s)Completed: `"t'—o d�cll IDq ft. it.
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Su.Well Location: \ n 3s-AID•
f)lN t l f, CT�� S �� tl. It.
F aality:'11%mer NanIc litY[Dd(if aplplicable)
37 7 —
Physicnl Address,city,and Zip �J C—
a at.IteMAatcs
M.q(::�S a Ci
c,�nty P:lrcet fdemifiention No.(PIN)
51).Latitude and tonpitude in degrees/minutes/seconds or decimal degrees: -
(ii well field,one lattlon6 iK sufcicrit) 2.C tea on:
gal oTa DQD' �o W -a -
s;a,I ,:arcxetr�uwa antraaar °m°
t,.is(arc)the wdt(s) ci menene or ©ITrmpnrary
!zv et}miasi r oed i far,I c, a era t o that fhc nv1!/�nor fwcraJ avR�rrpryul in accnrdoncv
i.is this A repair to an existing wdl: �Yas or O40 natb ISA N(",W 02C.O► l)or iSA Y(:AC 0?f.'.0100 We Cunsrrnrxinrr Standards mfd thin it
l�'drh iv a repoir.,�ll owAMKnVuR eoaar,.cnnn in Armotionmrrf"plain the anit'"r!r'the tal?Y nflh!c fen al hoshrat provided rn Nu wrf!owner.
r.,Vair finder i1,21 romarb.urtion or(in the MCA'91f1110 farm. 2.3_Slte diiagr:ttn or additional treU details:
you may use de back of this page to provide additional well bile details or well
R.For Geoprobe/DIST or Closed-Lanp GeW6cr'mal Welts having the same �M4trurAion details. You may aim attach additional pages if na Tmwv.
cansintclinn.Only I GW1 is needed. fndicate TOTAL NUMBER or-kvclls
il�SiRIlf—MO
9.irntal well depth below land surface. KW 24% For AH We11s: Suhtn$this form within 30 days of completion of well
Far muNiplc wr!).r tiu at,,da Pllte ifdt$camt(rxronple-3LZ200'and r�ltr 1091 con Marion to the f011MVing:
10.Stmttc Water level blow top of casiOF —(ft) Division of Water Reslrurces.IRfurmatian Processing Unit,
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1617 Mai►Service Center,Rateigb.NC27699-1611
eak?l*wm,Isrdvtvatvving,ute
( � 1 c�•c
11.Borehole diameter. 24b.F,gr reflection t,Ydls: In addition to sending the foam to the address in 24a
above,also submit one copy of this form WIibin 30 days of compidiae of well
12.Well construction metbw.. 1 iJ�(il J✓ cntnSIMetion to the following
(i c.aub4r,ra:try.cable,dircet push,etc.) Division of Water Recourses,Underground injection CORtro)Program,
FOR WATER St PPLV WELLS ONLY: f 1636 Mail Service Center,Raleigh,NC 27699-1636
Is— ltetltod of test: tom"+ ____ 24es Roe N'ater Sumaly&IuiccHon�Wells: Inbgaddition to sendinghn the fain to
13a.Yield(gpla) ills addresses) above, also submit one copy of this foie within 30 days of
Q a l p department of the county
,� Amotmt: 0 coin tenon of veil eor�cUuctioa m the county health depaftrn
13b.Disinfection type: where constructed
Itonn cW-1 North C.amtinn Depnament of Gnvinintnent.l 043111y-Divisnm of Water ResMute-s
`: Revered 2 22 Zat 6