GW1-2021-03552_Well Construction - GW1_20210823

828.622?241 p'l
Feb1519Q6;43p ClearwaterwaDrimn9
WE):X CONSTR.UC')i'ION RECOR.IQ(G'W-X) For lntelmni Usc Only-
t,ws?1 C,ontraetns lnformntloa: �•. --'-
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NC We Cnnttattor l:Mtlfiauion NtrmlMrS R C RiNG for ttlo OR tLiN6R a
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l:nmpnny Namr.
16 !NN&R C 1 OR 7liAflttG MA L
2.Well Corletrncurin Permit M
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rrah aj7plfwftleiwffrnrrrnalnnpwMaxQ.afIR C.rmmy.Srnlr, cRat-
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3.Well I1Sc(check well use): tt� IAL
WAtcrSapplyWell: itrOM
AsricultttratMtatieipAllPuhtic
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Gcahcrmai(Heating/Cooling Supply) �Rw9ktaltiAf WmctSnppiy(singie) R tr.
industriallt'.ommercinl Re hiclitial'Wal-Supply(Shared) .
Irrigation .'.g T A eta ttMrt.i► C`�rat Ddc MTD
Nan -';upplvW#4l-
M Recovery
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njectionell: 14. Q.
echatge �(lroundwaterRentediatinn t3 pCepJGRAVBLPA twC Setca�ton
torage and Raeovay
Salinity f3nttier ti iv? L -----ft
est [3Smrmwetcr Drainage tal Teeitnology 13Subg1dence Controlal(Clased Loop) 13Trncerso.al(Hcatinp�Caolin>;Seaton) Otller(ettpt8in undcr#21 Rcmarks) reset It. IL
a,Datt.}Raeil(s)Completed. D wet,IINV rr �i is
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am'. ° �-k�n 1 VC 17���[�L.t�� t�.r'� ft• a' � t � ._
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l'hysirnl AAAICcs,City,and Zip ft.
j/� i fy� xt R�NARK4
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Cinniy Patrccl identitication Na(PiNl
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Sb.Latitude and longitude in degreWmimuteslsecands or decimal degrees:
0 wall frehl,,one 1ntlangis nnf inientj C 62(' e-F1-1 roI an:
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A.Is(are)the well(s) Permanent or Dfempornry ipnatnrnnr(kMlificd WellCnrtt GWI' On1e
�tv atiminn lhla;rem,f hrrrJyCiMlfj+that tile.UV l(,)tare f wv)rMf'nWavt in amnrAame
i,iy this a rcpatrto nn cxisNngtvcll: 13vas or MNo n•rrh iM vVA0 n7.r#10D nr tsA N(.AC.A?C.B1A0 R'r.!l Carurrncrra,rSYoraian[t rmrt,haa.r
f,,+'rhic is a revoir riff nurkrmem rdl anawrr+Ginn Urjarmartan mul crptain the rurnrr e ofrhu •nplr of this record bar beryl pro04W In lfa[well mroler.
0:74ir realer 01 mamaN,s,scemn or tinifre harl nflhtsJiM 13.,S11e dot r m or AAdt1fon4t well details:
R-For GeoprohelDPT or(:lased-Loup Geothermal Welts having the same loot,may ego the truck of Wis page to provide additionnl well site demih tn•Weil
nnnslrrtctian,only I G1hr-I is needed. rndicnta TOTAL NUMBER of-%.clls can9t11WAinn details. You may also attach addiftonat pages if neecientnr.
driliad:— eMON
MMMMAL
A 7'atal well depth below land surfaces W OT pit` Jo.Nor All welb: Submit this form within 30 days of completion of well
inrnruh/pfcweilclisrrrftdrpRcerfd�erenr(nramplc-3LrAT!!Q'mrrtc�r 1007 ronaln►mitmto the follotsLig:
Ill.8tativ wares level Maw top of casing. (R.) Divisian of Water Ptmureea.tafhrmatlon Ih oeessiog Unif,
If caber 1014"k rrMmr Carl?%tray '•lf 1617 Mail Smite Center,W leigh,NC 274994617
ti_Borehole diameter: ! (in.j 9,4K%r Inlection Wens: In addition to trending the form to the addi+ees in 24a
I Welt construction method- t 1 ' n nbnvc,also submit one copy of this form within 30 days of eomplarltm of welt
ca►nsttuction to the following:
(i c,nuq�,mtap•.a�blc,dim.•t ptraU,etc.)
Divlalon of Water Reat umv.Underground injection Control Progrnm.
POR WATER SUPPt yV'l FU S ONLY: 16M Mall Ser0m Cenci,Raldo,NC Z7#99• 06
13a.Yield(gpm) "--i- Ned"of test; r.:ic.M)r Water Stalely&iaroetlen Welfa In addition to stutding the(brm to
Me oddreas(es) abnvo, also submit one copy of thi9 fort within 30 days of
13A.Disinfection type: Amount: completion of well CM5111 tletioA to thg cgmtiy lwalth dgMMcnt of 111t:army
wham txrtlstrrrcred.
I
Foam Gw-t Norrhl mlermDornrtmcm of 1?n+iMnmrntnl gmdlty-J)ivrsttHr of Water Rasona� Reviserl2 22 2n16

Well Driller Self-Grout Certification
Owner Pad D 141,ff,( New Well: tl
Address: u n , P.ltU->0,n a fair:
Permit:
I hereby certify that the above referenced well was grouted m appearance in accordance with
A County Well rules.
' �-�Well Dr ler: k�ec Me.0 cicuos `_--_
Certificate#: Q U:I --A Date Grouted: (X, Z-!
Construction: Grout
Total Depth: U Q 5 Tne:
Casing Type:—QVC� _ Thi ess: lit to-X-d
Casing Depth: Q U Depth: 2-D
Diameter: LQ
Weight/Thick
Height:
Drive Shoe:
GPM: 4