GW1-2021-03705_Well Construction - GW1_20210823

82M22-7241 p'1
Feb 1519 O5;43p Clearwater Well Drilling
WELL CONS'rftUCTION RECORD(GW"xl 1 or lntcmni UAe C)nty:
1.WdifAintraetor information: -' ------
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tveil`VoutradorNamr
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vC Well CnntracicrCatifolionNumber d.QD7ERCASIPi6 tiormu °
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CnalpangNmmv _ Fb.iTrNFsRCAB NGtJRTItBlNG t6orrauil iao
N��� i./`/�(/p � J DOM TA nt+►b1Crl�7i . TAIQIIYiSS MA'[S111AL
2.Well Construction Permit#- �J[ R t� i°•
US'all amfieahfr�veNcrmrrnrmlorllwrm/ls(1.a Ip[:.Crnrrety,Stalk Yarlrmcc,err)
3.1Ytdt Ilse(cheek well use):
V,.,
su •i'ersteaL
pplyWc11; ns roultural �Manicipal/public () 1t.ermal(rjeating(Cooi--tug Supply) Residential Water supply(sing*) M to in•
rIaIICommercial E)RcsidendalWaterSupply(shared) 1RGRO 81Nion >erne fl. R
Noff-water Supply wrile f�
it4onitoring ORecovery tr•
Injection el: R, R
Aquifer c Reehar6roun Cdwater Remedialion
19,Sa�RAVBLPACK [° �uC�yg METli6D
Aquifer Storago and 12erovcr)' E]Stilinity Barrier _ROM TO M
n n.
AquIfcrTcct Ditto mweterDrainago
Experimental Tcdmology Subsidence Control
ft. R.
Geothermal(Closed Loop) [3T(accr DBII'LiPiG LOG
Geott-.'(if-w- ti Return) •Other(a sin under A21 Rcrnae.) eD
A.Date Wdl(A)Completed:
JWctl 11)it .
So.Well Lnrndnn:
I acilit}d(laner llAmc - ii4iy go(ifaaplicAme)
l 1i , �ICi9
Physicni Address,Clt�,and Zip r A vy)
�t1 Sy
Camay Pnrcol(damificatitm No.(PIN)
51).Latitude and I'agittide in degreeslininalteslsecoodsordecimal degrees
(ifwait ridd,one W11oog in suirttelcnt) • I2•Certiticatlaft:
cVqa4
3D 5 - 7
$yga01 efCertiflwtVdGllCantraafor Data
!.k(arc)the welt(s) Permauent or ©17 emporara+
�.yyJmtag rNlr iornr.!hrrrhvrsnrljy drat the nvJ!(xf rrtrr fM'e►4 emnd7rYbrAaf aeanrpo!rcr
i.ih this A rtp8irtn An CidYdtig WrJI: Elves or IOIYO ,r+1f/ISA tif_'AC'a2C.410Urrr 1SA NC.AC 01C.'.111t10 WeNG�r+rlrncrian SYandardrmnl then n
q'thLr i.a rgm1r.,i11 m¢known rvr11 aataruenan irl(prma�ion an crplahr the aanmm nrrhu �pY njlfilr reeard hat'barn pmOdwi to the well Amer.
r.,rair render A.1 remark rcatitm ar an the heat of 8/ts.famt. -I&Site dhtgrtan or additional well dads:
1'ou may use the back of Iles page to prDvidc additional well site demlh or well
R.for GeoprobeAlIPT or Closed-L.nnp C,eolbermal Welh hAving the same axi4truaion details. You may also attach additimret pages If nocessarY
muminlction,onivIOW-lisneede indicate TOTAL NUMBER of%vclls
?�-ti S � ��f- �m'�.ri'l a [>. ve-rrM
9•Totat well depth below land surbec: IM4 2211a. 9'or Atl Wells: Submit brie form t+rithin 30 days of comptodon of Weil
1-er milhiptc wells lisl andeprrrs iftrefferent(exmupk-3(o17pP'mtd sLa17A0'1 const aion to the following:
10.Statie water level below top of easing: —(Ft) Division of Water Restntreea lafnrmat)on PrOcMirtg tltrit,
I(water fine!1s alvtvs easing line"•" 1617 Mats Service Center,litatefgi6 NC2709-1617
I borehole diameter. (in.) 2Ah.Fur 2kS up Vetis: in Addition to sanding the form 6t die add>ew in 244
above,also submit one copy of this form with)a 30 days of compledan of well
t 2 Weil construction method: ra>•nstruetion to the folirtwing:
(i e.rorge•,rotary.cable,diroA push.de,)
1?Ivision nfVl'a[er Rcemtrees.tindc><ground igjection Co Program.
FOR WATER S1;PP1 if WELLS S ONLY: T— 1636 Mail:3ervice C Ratelo,NC 291v9-1636
'Came;
lac Rot WAI�r Cu.,.a� re[Mtion Wells to addition to simding the form to
13%.Yieid(gpm) Method of test* the addrsss(cs) above, also submu anc copy of this form within 30 days of
Antovat
completion of wail consuuction in the county health department of tht:county
I3b.Disinfecttan
type: - w}rGYe eonattnctod.
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