GW1-2021-03803_Well Construction - GW1_20210823

Feb 151905,43p Clearwater Well Drilling 828-622-7241 p'1
1'WEIL.I,CONS�'RUCTION RECORD(GW-1� For lntcmal Use only:
!,W. CnnrraeMr`inf`or'mation:
I� ,y` � t4 W ZONES
/ --
tiRD7.t TO DESCRUMIM
Writ Co�llmoror Name
LNC:Wdll C(n/n��traf��glor�Catificafion NNtnnher. IJ(/) a OUTER CASING for mot6esed welh Olt LT�tER a e
U'A✓�' , akx t PROM fi TO tw fi. Di LRM' 711f P�9 MA't'CRIAL
Campnny Nnmc (� — L �•
�..11J�1 , � ILMIER CA81NGORTURtIVG ttaQsmatelo�edaoa MATr1+tAt
" D3AOfETE7t TAfCXNLtS
?.lirclt ConntractiaD Permit#: Two" TON, k In.a!!op/riirn5l�fuel!cansrmerinn parmOr(i.e.INC Cooney,S1a/G Var/amc,M-)
3.IM Use(cheek wcl]rise):
Watersnpp Nvell: I7.SCRB N
ppOK TA D A OWTMS TNtCKN664 MATEREA16
Agricultural Mtmicipol/Public tl A. & in
Creatltcrma7(19cating/Cottlin8 supply) Residential Water Supply(single) R fr., is
[ndusiriallCommerciat Residential Water Supply(shared) allf
lrrt^atifm NROM TO MAT75RU4t srwPtAC6MC'tr?tMODd.AaTDtJNr
Non Ayn1,erSupplvV►'ell. is ) ±0-
1 dMonitoring Recovery u. finjection Weil:
_
Aquifcr Recharge E3Groundwater Remediation
19.SANn/GRAVBL PACK a hie
.Aquifer Storage and Recovery []Salinity p8aiei "OK TO M T tAG EI{tt t/1CtTltttiTML7I10D
AquiferTcst [3SmrinwaterDrainage:
btperimental Technology [)Subsidenec Control Il n•
Geothermal(Closed Lextp) OTC- 20,nRIt.T.1NG L8C JoUsch ad etbetels eaeaetea
FRtI>rt TD CORK.Mrdwaswrom tvm grain Aft eur,
Cretuhamai(HeatSn actin Ren,m) 'Other(ex laintmderf121 Rcmevles) i tt. 100 ft
4.Datewetl(s)Complette�d�;2:z►-U p well 11V
.5u.Well Location:
N1�C,Y1Q L�lJs rt. ax
h:'f Q�, ,
htcili )aomllamc Facility
-
Physoirnnii'Addre�c�s,City
and+ EL
7.ip
21,REMARKS j r
CoantY Pnrcel Watifieation No.ON)
51).i.atirude and IMAitude in degrees/minutes/secondsordecimal degrees:
i werl Geld,one latgont;is aufl7cierd) G _ i (` rfication:
035
A.Is(are)the well(s) ermanent or DTemporary :ie nmare t''wilrml Well Cantrnetar Date
l v xt}'nlVS ibex erm,1 herrhvcrnlfj,that the tw.dl(I m-ar firm--.)e:rmsrnnred in acunrdm"rre
i.ir;this a repairtn an existing wen- Oyes or g2rNo ,'ill, tif,.'AC D7.C..0109 or,15A NCAC.n2C.Moo Mell Cons/rnrnna Starrrtarda and ihm n
f''fl lr icn--epee--,fill mrrl7fann neJl»asrrnctfnn irrfn.mmrnn r rrpfnin dye Muter nfehc tnJ?I'nfllttt N rnrrl GaChf't AIJrAVfll8d 1A1he well ntvr7tr.
--.,vole rmdrr G?1 rcmnrks azrnctt rtrtmlln:Karl;n(thlxjntrn.
. 23.site diagram or addifional well details:
R.fror Geopmhr/DPTer Cinsed-lAnp Geothermal Welts having the came Vou may usa fire back of this page to provide additional well site details or well
mnsmiction,only I GW-J is needed. 1'ndicate TOTAL NUMBER of urlis construction details. You may also attach additional pages if necessary.
l�'tTAL)hy^+1,�„11t��NS
9.71'ntat well depth Now land surface: S— _('L) 2'1-% For/ill Walls: Submit this form Within 30 dal's of completion of well
l�rr r�tdiip/e,er!lc rice ntirl gHhr fdljl-ennr(rsnmptc-3(q?1no•and�2ir lnn� construction to the rdloil'iag:
l�
I ti.$tptie tYAtr N Icve l below trip of casing: �`"� (h.) Division of Water Resourees,Information Pmeessing Unit,
11 ttYlh:'r ie,T.!Is above cnring ax, •" 1617 Mai!Service Cetlter,W teigb.NC 27#A-1617
l_%reholedlameter. _�� (in.)
J
,yam- Zak F 1at_Stiop Welts: in addition to sending the form to doe oddf+ets in 24a
I Nell construction method: rL' L. ^ above,also submit one copy of this'form within 30 days of completion of well
6 C.nnac,minty.Mble,dircx pw lt,etc,) eonstrnetion to the following:
EYi
SC:PPLY WELLS ONLY: Division of Witter Rellotlrmi.Un6rground injection Contra]Program,
1636 Mail Service Centew,Ratcigh,NC 2709-1636
m) 4�- lllethadoftest: 2.1e, For WRIer Supply&Ig�tion WdtO In addition In sending the form in
the Wdrrss(cs) above, also submit note copy of this form within 30 days or
on type:, Amount: comptetion of well construction to the county health depannIcnt of the crmnty
where constructed.
Flynn G1A'-I North Cnmlinn Depnnment of tinvircinmrntit<?,obey-rxvi.�ann of wwa Itesmerem i Revimd 2 21-2016

Well Driller Self-Grout Certification
owner. U ► R!C_ &w Well:
Address: C{ Q�l� r? Repair:
Permit: G(.3 Z I dD �f�cn
I hereby certify that the above referenced well was grouted in appearance m a=rclmce with
all County Well rules.
Well Driller:' �- /Zan---
Certificate#:, 2(1 Daw GmAO& 1 DU" t
Construction: Grout:
Total De JlB�~ Type: C
�' U C- Thiclmess:
6�'►� �d
Casing Type: �
�g Dept,; 100 Depth:
Diameter: 11`4
WeighVThick:_
Height
Drive Shoe:
�--

Date.-
Well Case: Well#: WO
Name: M'l C"a-L� c!3-�W,(( -
Address: I bq l Nrt'Ge(JAI Gt �:Gi
f Ici-C. "i-). &-x-
hump has been installed, well head ready for inspection.
Sign:
Cte"wwtew WeU, Dri,tiwt,g