GW1-2021-04046_Well Construction - GW1_20210823

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 p•j
WELL CONSTRUCTION RECORD(GW-1) For internal Use Oniy:
I.Welt CnntrRrlar Information:
PROM 7O DIlN 1073
tVc)t ro4noraqur IVamt: f rc fi.
(NNCC RyWell Cnntmetur Cetifrcation Nmnher 'ER CASING tortnaiB-Rued Melb ORLrIi t r!
t I X�t } ✓V PROM TD DiAME7LR I. T11ICKNOS MATERIAL
it, ". tI V in.
Cmmjnny Namc —
tb•11YN1iR t;A31NG 4R 7'IaSINC tbarmal ctoaad-too
7.Well Construction Permit#: PROM TO DIAMICrER� •rntClavEss MAtFA1AL
i.ixr all applirnhfr,tali CrinrrrpafOfe parmOr(La!/1C,CnttMy,Sla/r,variance,arc.)
D in.
3.Wrll Ilse(clteet(well use):
Water supply well: 17.31CRIIENmom To DIAtY1Sit1t sLorstzs 7xtclavtrss wrArertut
Agricultural �Mtmicipal/Pablic () ft. t,.
Geotncrnuil(lieating(Cooting supply) &Residential Water Supply(single) ft. in.
tndusirial/Commercial 011csidemdal WatcrSupply(shared) 1RCROlIr
irri ation _NROM TO MATE L sMPUaCEMEYr],BfltOD&AtdDtnYr
ft. R
Nnn-�'1'ntcr Supply Well.- a V v
Monitoring R¢Covery tt. fc
Inje:enon Well: n• it
Aquifer Recharge ©Groundwater Rcmcdiatinn
19.SAMllGRAVEL PACK eta b1e
Aquifer Storage mad Recovery Salinity Barrier 7;17E
WiA•t IAL ptirtrtCtWN6NTMFTli00
AquitcrTest [3SmrmwtiterDrainage tirtperimental Tedinoltlgy f3subsidence Control a•
Geothermal(Closed Loop) [3Tcacc, 20.DRILLING LAG attach oaatshrak' taetx+sa
F60M 1O D6 iCit1r17Or(tsbr. rdaen,is r ra4r rke,stu
1. Geothermal(iicatin oting Return) Other(ex lain under#21 R=arl.-s) tr, fr
d-Date Wells)Completed: Well IDU R• 4�ft. lU,
Su.Well Location- R -
+ ladlit�:'tlwncrNa,nC FacilityIm ifapplicabte)
rl>ysimI Address,City..ao,tp n
21. ARKS
C:wnty lWeel idcenifiatitm No.(PIN) V1.
%h.Lalitude and loti itudeindegrees/minutes/seconds or decimal degrees:
(ii%Voj ficid,one let%ag is sufficicrt) '2.Cerd sention:
Si (arc of Oertirad Well Canrraator Daio
d.is(arc)the vrell(s)t�Pcrr,tanent or ©ITempDrary
IEv 7,EA.g r m farm.I herOv a"01 that die wdIN knr haerel cveeomduJ Ar oemrdorrcr
i.is this A repair to an existing wen: Yes or No Mdrlf IS t.tiC•AC:02C-Oi00 or ISA NCAC Q2C.021i0 Well Consfrncxiaa Staiulards mrd 1Am it
{,rfhi.r iv cr repair.fill OwAmwn wall.0marveaan inormalion Erld explain the errant e r he cfapy affles record hoe Ai1dn pmVfded In the Well Owner.
,,wir under t2/remarla=wx ar nn ilia hark ofthb fornr' 2.3-Site dingrrtm or additional well details:
&.For Geoprobe/I/PT or Clused-Loop Geothermal Wells having the same Vou may use the back of this page to provide additional well Ate details or well
exinsin,ction.only I CTW-1 is needed ihdic ate TOTAL NUMBER of-tYclis c iijaruction details. You may also attach additional pages if necessary.
drilled: 5141IM"TAI.IttiSTRUCTTONS
9.Total well depth below land surface: d t�•) 24.% l+er Alt Wells: Submit Otis form ivithin 30 days of completion of well
J ar rauhip&K•ril cGtt alid..pffrr jdr�erenr axampk-3n10(r•ond 2@i00i eonstrurAitm to the following:
10.Static water level below top of essing: (ft.) Division of Water Resources,Information Processing Unit,
i/'a art.r(nee!is ahme owng•vac l�L 1617 Mai Service Center,Raleigh,NC 276"-1619
I I-Boreholedfametcr. {tn.) 24b.For injection Wens: In addition to sending the form to die alddremi in 24a
(�9 ahove,also submit one copy of this form within 30 days of completion of well
12.Well construelloo method: ® I 1 construction to the following:
(i C.tinge^,mt:vy.cable,direst push,•ne,) t
Dlvislon of Water Rrttaaroec,Underground Injection CDRtrD)Program,
POR WATER SUPPLY WELLS ONLY: f( , 1636 Mail Service Centcr,'Rateio.NC 276994636
b `I{fl/d`. s
13a.Vitt(gpm) —ifethod of test. 24c For Water Sunols&IaiecHon Welts: In addition 1,sumling the frnm W
i Ilia address(cs) above, also submit one copy of this fomt within 30 days of
tab.Disinfection type; Amount. camptation of well construction 1n the cocmiy health department of the county
whore constmered.
Form C,'-I North Cbrrtinn Department otlinvininm-mnt QunLty-Division of water Resattrces j Reviset!2 22-2016