GW1-2021-04106_Well Construction - GW1_20210823

828-622-7241 p.1
Feb 1519 05:43p Clearwater Well Drilling
WLLL CONSTRUCT_1ON REC GW-1) For lntamal Use MY:
1.Wcl ntmirtor Information: I, — -
�� 14,yy'A ZONES K 1
S PltOaf 20 DES
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IVr)1 .onntadorMaine W ft.
NC Well Cnootelor Cert/i�fic�alion Nurnba TO R t: AYG mad t' uy
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,M CLaM1�6>Z Tffi NA77CR1AL
2.Well Construction Permit#: RAW tn.
i.lal MI n/rydrrnb/r wrllrvxtrrramlon parmrts(Ld;t//C,Cmrnty,1Yalr,Yartama,err_)
rt. R tn.
3.1W ilhc(check well ttse): --
Water Supply well: 7 s T>nrut.: vtx►t ro
Agricuknral �MunicipoUPuhiic o f► it in'
Cmalheraw(licating/Cooft Supply) mRewidentiat Water Supply(single) fr
Industrial/Commercial esidemial Water Supply(shared) t8 QiPI BrROD&AMOt1Nt
aphq TO
irri anon r ap R, �� � �lj �`(Y1\
Knit-Wakr Supply W01L^ f�
Monitoring Recovery
Injection Well:
Aquiferltecbatgc 130roundwaterRemcdiatian fYSANIUt=rtA�LPACK [o
llq y >Q{tlWC£MB[4T6r1ThhdD
Stdinity Barrier ROM �
Aquifer Storage and Rel:avcry �• - fl. n.
Aquifer Test E]Slnnnwatcr Drainage
Experimental Tcctmology [)Subsidenec Control & rt'
Geothermal(Closed Loop)
�Ttraccr ro.DWI.LINC t.OIG
�
FROM
Geotitetmal Kcstin ooti nR Rctum) dti>=fe% in tinder 421 Remarks) fro �y�
tt. . V 1 C, V
A.Dare U'O ffpi)Ctmnpteted. Well IDV
So.Well I natNnn: I i t1`1 ILA-AOLI g � sr.
1"-A OL r K- I L`�l S i t-IL n.
PadlitydOuo+cr�lamc Fxt1t17tlDii(tfapplicabie) _.,,:':
31�s C'iraf)A\)c Or. Q fr.
P sicul Addresg,City,and Zip 1J L
'7,t. ARKS
C,u,uy Pnteei rdantiftratian No.(PIN)
51).i.atitude and(onaltode in degreeslrnlmrteslsecondsordecimal drgrees;
Or welt rrcld,one tet9ong is Sufficient) t ' Certifi n'
q 30
r'ckrtirt�rwalcontraetor pate
b.Is(arc)the wetl(s) Cermaucat or ©ITctnitnrAra'
tiers form,!hp
wJ!v auKljy That the.n�31/xJ was IN mrr�rAnern►r�zd Bt accerda rcr
hot
7.tathisare ail-mAnctdsdo wr31: ��..r.�lYes or io v+dtlSA:vG:K.'A2Cd1l0U nr1SA,Vl:ACO2C.0200WdiCo rten"i�rn'.ttandards•andshot,;
rfddv it n ryro r.fill mirbwwn nv4l e&zvracrran irtrnrmadmt and"Ida" d,�,rorur, !rrho �tpY njr(t/S rernrrl ih!t9t pmtrhle d In the lu ll mvnrJ.
r.,vir under h /remar4s wzrtaa ar rm the bark'If M MOM. I&Site jiliagram or additiond well dMils:
lroc may use the tmek of 1114 page to Provide additional well site details or well
R.For GeoprobeMPT or Gamed-Lang Gewbartual Wells having the same eilrIstuUinn trelail� you may else attach addititmai ptrges 1f nocesserY.
txmstntction,only i GW.i is needed. Rtdicato TOTAL NUMBER or-kvclls
drilled: _ _.. eta ,rr-r.r fiti5lRli ONS
9.lfotal wc11 depth below land surface: 37 (
J R•1 2,& ErAil halls: Submit this fmm kitte days of 30 d of completion of well
Far mnrdprc,Neilrtist at;daplhtifrff'erntu(rxr+mpm-3C!+12( ira(nnde�1ii aoi ctvrigtr Ctitmtothefolitxvlag:
10,Static wager level below top of essiag: `C-U- (ft) Division of VYater Rerirlurces.lydbrmatian Proc'armfi Unit,
111.S ativ l Is,tevtwe l b tw t o 1617lIIII Scrvi e,Center,Wcigh.MC274"-1617
li.1lomllotediamcuer: i i�__ �(in•) Zol.For injection JKSW In additirmjto 6011di118 the fonu W dicaddra+s in 748
atrovc,also submit one copy of this form within 30 days of tmmpletttm of well
12.Weir cimstract[tm method: cHutmetion to the following:
0 c.miser,rotary.cubit,direct Ptah,etc,)
Division of Water Re»aurcet.Underground irtjeetion Coattrul ram,
ibR WATER$t PPr_V WELLS ONLY: 1636 Mail SmMee Cernrr•,Raleigh,NC 27699.1636
LJa.Yield(gpta) Methtul or test' �j 24c ttr Wa1cr Runniv&iaiocHon WdiS in addition in surtli g the farm to
the addross(cs) above, also submit one copy of Ws form within 30 days nF
tab.i)isinfectian t _ Amotmr. comptal,an of,yell consuuction to the comity health department of the county
Yp� - whore coaatmeted.
North GhmlinnDapnatnont of t:nvlydnmrmtal Qtwlity-Division of Wow Rootnucac Revived 2 22 2oi d
ltaan C11M-1 j