GW1-2021-03724_Well Construction - GW1_20210823

Feb 1519 05:43p Clearwater Weil Drilling
WELL CONSTRUCTION RECORD (GW-I1
828-622-7241 P.1
For internal Use Only:
1. Well Contractor Information:
)DSh PLe�n
Well Catmint Name
' Weil Dunmire mire Certification Number
Company Name (`�4� I ((.�� C
2. Well Construction Permit #: c 1vD 1 V J
list all applicable Iva crniftrtcnon permits (1.c. UIC. Cann iy, S[alr, Variance, etc)
3. Well Ilse (cheek well use):
Water Supply Well:
Agricultural
Geothermal (iacating/Cooling Supply)
Industrial/Commercial
�IIrrigation
Non -Winer Supply Well:
Monitoring
injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
0Municipal/Public
E.?*&dentist Water Supply (single)
Residential Watcr Supply (shared)
Ci Recovery
QGroundwatcr Rcmediatinn
Salinity Barrier
DStnnnwater Drainage
DiSubsidcncc Control
ETrnccr
�Geothermal (Heating/Cooling Rom) ijIi 0the' (explain under #21 Remarks)
4. Date Well(s) Completed: L. - 2 Z. " y' Well !MI
Well Location:
Lunt n S i V1r1 ( V
l acility (hv ate) tree �Faeility iDd (ifopplicsble)
or)
Physical Address, City, and Sip
Calmly Parcel rdcmificatian No. (PIN)
fib. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well add, one latlleug is suilicicrtt? O [ n35°C9 t3S- 05s 344.uSw
6. Is(arc) the welt(s)Permanent or ©rrempnrary
7. is this a repair to an existing well: EnYcs or , 'No
/fdrir is a repair. fill malarawn swell aorwrneetnn brfnrmation ant plain the nature ..(the
r;pairunder .21 remark stzrlanornuthe burl ofditsfirm.
8. For Geoprohe/DPT or Clawed-Lonp Geothermal Wclis having the same
ionslnictinn,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
tzar multiple welly list all d tplat jdferent (example- 3@10(1• and s@100)
sus
Ill. Stride water level below top of easing:
rarer rare! is ahrva casks rru: "l I
11- Bottebolediameter: (in.)
12. Well construction method: VD ' (1r -4
(i c. mrge-, rotary. cable, direvt push,. tc,)
(ft.)
FOR WATER SCPPLY WELLS ONLY:
13a. Yield Wpm) 3 Method of test: V✓1.
Ci
I3b. Disinfection type: Amount:
Form Caw-
1
4. WATER ZONES
PROM TO DESCRIPTION
ft. fa. 1 .
O. n. "
1S.OUTERCASING (for moldeasedwells ORLC4ER(ifs ljclblel
PROM TO DIAMETLR THICKNESS MATERIAL
1 ft. -70 ff. (i21/ !in. �UC
16. INNER CASING OR TUBING (Leatbcrmal doteadaop)
PROM TO mowTatanESS MATERIAL
B. , ft. in.
f4. R. in.
17.SCREEN
PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0 10. ft. in.
ft. ft. in.
I8. GROUT
FROM 70 O. D IL MATERIAL1 / i JI i- d EINKLACESTENT METHOD dcAMOt7NT
/ H.
f`
It. R.
19. SAND/GRAVEL PACKdf nnfalicable]
PROM TO MATERIAL .EIVIK ACEMENT METHOD
n. IL
a. ft. -1
20. DRILLING LOG (attach additional ifncansary)
PROM TO ffestrtirt.pate
i ft. Jp ft- ) *di '1"��
7D ft. (7 ft. %t-C/v)) J
Cf7f" (1790. / te
ii, fL 9'4jti � L �' `
ft. at. 0 .-'o -v\ca
21. REMARKS . ,...rj`,i r`.
22. Cereiraylian:
�23
Signet of Certified Well Contractor
By moan dttt• _(arm, 1 hereby rae r/fj• that Mc we-1W war twcsv) cvn inter d in accordance
with /S,5 NCAC 02C A100 or 1 SA;CAC 02(:.0200 Wen C.nsrrnrnnn Mordant< mrd that it
zany rifilris record Nos `Arm provided to the well owner.
2.3- Site diagram or additional well delaifa:
Von may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
5POWTFAT. INSTRUCTIONS
21a. For All Walls: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh. NC 27699-1617
24b. For infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Reaour ees, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. ).or Water SunDli• & Dilation Wells: In addition to sanding the form to
the address(es) above, also submit one copy of this form within 30 days of
comptetion of wen consuuction to the county health department of the county
whore constructed.
North Cbrolrnn Department. of Elwin -immoral Quality - Division of Water Resources
Gale
Revised 2-22 2016
22. Cereiraylian:
�23
Signet of Certified Well Contractor
By moan dttt• _(arm, 1 hereby rae r/fj• that Mc we-1W war twcsv) cvn inter d in accordance
with /S,5 NCAC 02C A100 or 1 SA;CAC 02(:.0200 Wen C.nsrrnrnnn Mordant< mrd that it
zany rifilris record Nos `Arm provided to the well owner.
2.3- Site diagram or additional well delaifa:
Von may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
5POWTFAT. INSTRUCTIONS
21a. For All Walls: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh. NC 27699-1617
24b. For infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Reaour ees, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. ).or Water SunDli• & Dilation Wells: In addition to sanding the form to
the address(es) above, also submit one copy of this form within 30 days of
comptetion of wen consuuction to the county health department of the county
whore constructed.
North Cbrolrnn Department. of Elwin -immoral Quality - Division of Water Resources
Gale
Revised 2-22 2016