GW1-2021-04042_Well Construction - GW1_20210823

Feb 1519 O5;43p Clearwater Well Drilling -724� P.1
828-622 ••
WELL CONls'TRT7�TION�2ECORIa(GW�l) Fnr lntcmnl Use only:
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ft: J(� / n. : V�(/
t:nmp my Name ` , ~16,INNER CASING OR TRMMG et —al claseddoo
2.Well Construction Permit#: . t�l)Ii- 75, r
O TO1se
osAntcTER in. T"MICKESS MA1trR1AL
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3.Well li (cheek well list): a' (�
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t reothcrmal(t9cating/Cooiing Supply) aidaltial Water Supply(aingie) in
industrial/Commercial DResidrntial Water Supply(shared) •T&GROUT
lrrinotion u ROM 7b MATERIAL mvin AC-Y1GYrMMOo&AMOt1Nr
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charge QGroundwater Remediation ft. R
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rngC Mel Rcctwcr E]Saunity Batticr B elm TO MA IAL tRVirLAcErtSNTMtrntoa
t Dsoci mwiltcr Drainageal Teelmology []Suhsidenee Control ll R.
Geother nal(Closed Loop) 13Treccr 20.DRIMAM LOG fatUtsch frm-M
BR FM I TO 0doe.h1rdam,uroWreekt raln etc,
Gcathcnnnl(Hearin oolin Baum1) 'Other( lain under N21 Rcmttrlcs r tt. � !e. S' �- `/�
d.IlaacVY<n(s)Completed: "Z{ Well IDN -
Se.Well Location:
l-:teilityr(luvrcr?tame Facility iDiJ(ifappllcahlr.)
21.REMARKSAZA
Cannty Pareel Iden6fleation No.(Ply
5h.Latitude rind longitude in degrees/mimates/secondsordecimnl degrees:
(ii welt( gone tat9ang issucirntJ ;!Z Ce l ilea:
z� � i o i tiv �,Z y,4 j
b.ls(arc)the well(s) trmaRent or DTrzn tnrRry ::iannu c of0wiried Won r Doge
�.�( l v.u1ming rinv.,rrm,1 herrhv veylif.,that lire twdl(A)rear firm--)a momtred M rteonrde77re
i.le this itrepairm aft existing wen: Elves orp[JNo I•.tirlSA.tie_ACUC.O10Aor15AYCAC82C'.4200 Well Comfenrm)?MondorA;and Mina
1;tl,T 1�:>------tore fll mrtknnwn wrJl vvt,rnrrtrmr it nmrn(inn r pfnin rh,rurnnr nfrhr tap),nfthk rrrnrd har boar PMK&W la lit'Well nl ow,
r vair tinder Of rrrmarkr wrllnn arm 111'c hurl•off)",fnmr.
13.Site tllagram or additional well details:
R.Fir CmIlroheMPT or Closed-Limp Geothermal Wells having the came Tou may use the back of this page to provide adcriliona)wel)Silo details or well
unnctmrlion,only 1 GW.1 is needed. Gtdicate TOTAL NUMBER of urlis construction details. You may also attach additional pages if nemssary.
drillctl;
9.7rntat well depth irelow land surfilcs: _(D.► 2l19 col•i!1! Weillt; Stlbttlit this form Within 30 dabs of compleiion of well
l rr"'Iftolr otear l:u mli d rprlu ifdljlerrmr fesmm�le-3�240'mtd 100�
cungMtedDit10the follOITing;
J 0.Sta6e wafter level beinn top of Iasi ng: (l1.} Division of Water Rewtrccs,Information Processing Unit,
If"«•n(rrr+rtrtlsrrMrvtrnslnR.ur J/
1617 Mall Scrvke Center,Raleigh.NC27491-I617
19-norcholediametcr: t � (in.j
zah.For Iwieceion We0s: In addition to t;erlt[ing the form to the nddreas in 24a
12.Well construetlan method: 0 f/ nirove,also submit one copy of this form within 30 days of completieae of well
(i C.Mrs¢-,mnrQ.r..><,k,SlirRt pt1511,9C,)
construction m the following:
"MR WATT R St:t'PL1'WELLS ONLY: Division of�i'ater Reliourmi.Underground Injection Contrail Program,
1636 Mail Service Cenirr,Raleigh,!VC 2709-1636
13a.Yield(gpm) method of teat: 24c, For Neater Supply&fakctlon'Wells: In addition ro sending the form to
the address(cs) above, also subMit One ropy of this form within 30 days of
tan.Monfeermn type: � ,Amount: compaction of wdl cmull action no the county health depawncill of the aminty
where eonstracroet.
!°ant(:1k'-1 North C-nminm DcTnrlment.irtin.•ir inmcnt:rl gaalitg-rhvisrnn of Water RasmuVen Re eixed�^-22 201 R
I

Well Driller Self.Gnmt Certification
Owner. �,V S LI?OS�QV-6 New Well:
Address: �U �I C�rcL!�, r 5� p :
Pmnit•,
I hereby certify that the above referenced weR was granted in appearance in accordance with
all County Well rules.
Well Driller: Aof) SOS'
Certificate#:. � Date G �" Z Z�'
Construction: Grout:
Total Depth: q P,
Casing Type:^, V� nAftess: M a 6
Casing Depth: 110-- Depth:
Diameter:
weight/Thick
Height:
Drive Shoe-
GPM: