GW1-2021-03747_Well Construction - GW1_20210823

828-6322 72A•1 p,1
Feb 1519 05;43p Clearwater Wall Drilling
WELL CON T10N gECORD LG_W_--Il For Internal URe Only:
1.Well Contractor Information:
lt)NES pfscmt�rioN
�/ PROM 7n
1Vr�1i_(�:rn�ura�da�Nam�e _
wall:OR Li?lER a c
NC Wen Comnsnol Certification Msmber lS(1R1TElt Ct1S1NG DIAIvli fLR rUi ass
1#ROTA TO ry-
n.
I ft. �` G Jed rDrllsmaea l
Company Name "b.(TfPiEA CASING t�R'f11811�1 NATERfAL
•PRON TO D1AtNLT6R
2.Well Constructian Permit M Is. it. In.
i.i.ordi applieflue well cvmunreriaaarm pler 0-1)IC Callwy,Stale,Variance,e+c.) ft. ft. In,
3.Wcll Ilse(check well use): 17$C 7Rtctavgo tMATURIAL
WA ter Supply Well: -MOM p• ro � i,,,
Agricultural 0MnnicipaUPubkic p
Residential Water Supply(single) R fi. °`
Geothermal(Hcating)CoolirtgSuDply) PP (•• S )
Industrial/Commercinl ResidClId2l Water Supply(Shatod) ' S. MA eu►L nu,rllec �atlrtrtorta�atoular
T�l n+ 1
[frl Orion ft, tT..
Non WilterSrtppiyWell: fc
Monitoring Recovery tt.
injection Weil: ft.
Aquifer Reebarge E3oro,mdwaterRomcdistion i 19.SANB�1�ygLpAC1( [ ye IItRrACSM118NTM�rOD
AL
Aquifer Storage and Rectnverl' Salinity Battier r_
Aquifer Tcst oStortr w0cr Drainrtgc
Experimentai Technology [3Subsidenee Control 1; �
2a pRii3.1NGLOG Rtlaeh pit Inc see
Geothermal(Closed Loop) �Tcace tnmx TO a eotw.
Geothermal(Hcatin oo[[nx Re wm) Other(explain under#21 Rcm2t'1ss rt. CJ >2
c rt. G tr. '1
a,Date Well(s)Completed:___.__-__._.___.well ION �`� rr. RL
Well Latnrtloo:
l� t. n. f
I�aeilitv'(lursrrTIame '' ��-t-(�1 I�e� - FadlitwlDC(if:,pplicsbtc)
114
Phy!!1wd Address,City,and Zip
2l•REMARKS err Cry,
County Pareel identification No.(PRJ1 .,p,l• 'u�v�1
5h.1,Rtitude Rnd longitude in degrees/minutec/seconds or dMimnl degrees:
(i.-Nvoll fieid,one latgong its snirtelCnt) V , :2.Certification: C J y/
L,` of C.enir,ed well Cammietor
4.h(arc)the well(s)operlanent or OITemporary that the,nv:0 ma F,rere)cmtarrWJW in ocwrdance'
Rv.rr},miag r/de.,an»,1 hnrhV crrrlfjr try
7.is this.a repair to an existing Wcll: ElVets or No ,tall,1S,4 YCdC.•024:.0100 nr 1SA YCAC 07C.'.0100 Writ Cunsrrncnair Sfaadaxte mere roar rr
i,r'ddr is a repair,fill alabiawn uvli eonstr•uctlan irpfarinartan , esrptain the rraarn:nl-nc" [np)r of Ibis MrY�rrl l err llP�t pme'h✓rd la flit Wr!li riwnrr.
r,lair ra,der A?/remn►iFs SCrflmr or an elm bark of ruts fam,. 23.gtte diagram or eddiflonai well delleft
R.For Gen roheMPT or Oosed-1,on Geothermal WC11s having the Same com'may Lisa I tl a back u this page to provide addadditional
ag if 11 site derails or well
P P constructioo tirtails. You may also attach Rddititmal pAgec if necessary'.
tmmstructian,only t C.V.`-1 is needed. hidicote TOTAL,NUMBER arl%M119
driilr:d:_..__ .__ �nereimrAl 1h� 1�,CTI��
?.Toult well depth below land surface: _ `l '�� iR•) 24a• I or ni!We1�: Su n title form-tvithin 30 doe's of compiefion (if well
l-ar nrrrliipteµrllefite olidrpllar fdrferrnt(riampla-9(a?TO(1'ond e@+r1091 CpnQtruCtiOn tO the f01101Cing:
111.80tie water level below top of caving: V (ft.) Division of Water Resouree-%Information Processing Unit,
1l'uvrnrrIcm!tsalrnrecast+,g,nae"•"1 �( 1617 Mug Service Center,Raleigh,WC276"-1617
1 i_Borehole diameter- �() I_✓ (in.j 2•th.Fnr iRk1gg Wells: In addition to sending the form to ft nddress in 241
R)Dvr:,also submit one copy of this form ivilhin 30 dayS of eompitdltrn of Wdi
IZ Well ctmstruellaRmethod: —` gpigtntetionto the foilaWiti r
U c,ouge,mhrp,cable,Oired ptnh,ctc.l
Division a tfWi35 MDRelourcm Underground ii Service Ccntar17;atelg�,NC 27b�9 1636 ection ContrA Program,
rOR WATER St;PPI,V WF.I.L3 ONLY:
13R.Yield(gpm) Method of test• ���� 2,1c.l'r Water CutlDly&ioieetlon Welts: in addition to sunding lice corm to
the oddress(cs) nbove, also subnue one copy of Ibis form within 30 days of
I3h.Disinfection type: —_ Amount wmptetion of Well construction to the county health department of the county
Wtmre constructed.
F.mn Cit4•-1 NorrhC.nmlirmDcpnrtment.)rFnvioinmcninl Quality-Division of Watct'no9m:rcec Reufsed2 22-2016