GW1-2021-04141_Well Construction - GW1_20210823

-- -`� — 828-622-7241 P'1
Fels 1519 05:43p Clearwater Well Drilling
WE&L CONSTRUCTION RECORD{GW�><1 For internal Use Only:
1,�y r�11CnntraetorInformation: �• - -
,
�( l �1 i W LONES
c 1 �v rteoat o t►pBCRti'1 FON
Well C:ontraclor Name
0.
C WrIi Cnnhaclor Certification Number DjJTFR CASj(tlf'
ff ff tnt ro D1Ad1ETLlt ( B83 PIATERIAL
Z �( ��1 1 I( fr. % tfr�5 in.
C.ompnnyNamc t6.INNER CAM NCOR-TItBING tkOttWttlCK1,IDQ T8A1AL
iraoK To ouot tnIdaarsas
2.Well Constractinn Permit#: ft. in.
i.i.ra all aNdicehle,veil ennrrnrminn parmas(1.ea U1C,Calarly,-9a1e,Yar t—,e10
Ee.
in,
3.Wd'Il ltsc(cheek well list): 17. R8, N ntAtxertst 's �tcrorsss TaRua.
WAterSapplyWell: rtotut To
cultural DMunicipatlPuhlic () �• H 'n•
Geothermal(licating(Cooline supply) E)Residential Water Supply(single) tr.
(nAusirial/Cnmmerciutl �Residential Water Supply(shara) 1&GROUT q �.Ryt ooa�AMouMT
N H MAIMR L atNrt.A
phut^Dtlnn fl. j'�',
8Non Winer Supply Well: V fc
hinnitaring Recovery 0.
lniectinn Well: f/. R•
Aquifer Reehar�e MGroundwater Rcmedialinn 19 SarmreR,ivB pp A Di We
L
Aquifer Storage and Recovery inity Barrier 10- d r4 M1OA u ffiNTt� nt>rl
ES:d n°n
Aquifer Test OStorinwater Drainage
Eixperimental Technology []Subsidence Control �- n•
Creothetmat(Closed Loop) DTrnccr 20.01i1f.i.INGL4G dtae4b 1 M1y,akt , Feu
pR� ox To 1
Geothermal(Hearin Holing Return') Other(explain under021 Remarks) lr. r r
ao
!.IlatcLS'etl(s)Completed: n^st _ !Well II)tl
fe ,
Su.Well l.nca
�`rrJA n, fL � � O
I--sciiih ourerrNmme Facility 1110(if a tiplieabne)
X l _vi. ft' �� •1^Crr�v U
Physiani Address,City,and Vp
21.REMARKS
Cann . Pnrcal Identification No.(PiN)
Sh.Latitude and tore itude in degrees/minutes/secnndsordceimal degrees:
(io..clt field,one 1a0ang is suir%,icnt) 2 'iClrtifipt on:
6.Ware)tine wdl(s) Ptrmnuent ar D'I emporary
Sipnamre of CQtlficdwell Ccmtrnetor Data
By ar}'ring rhir fiorm.1 hrrrbv r,alrlfy char the nwllfap rrcur(wdm,)coin"nomwi in orzvardmrce
i.1.4 this.a repair tonnc-Astiagwen: Ives or 1?SiNo td1h)sAW_-ACO2C.p1011or15ANCr1C4D2r.'.t121/0;ve11CnnsrrncnaarVandardamrd,hmrr
;''this ix:t repair.full ourkarouw ivr.N aoaslruclirnt irlfnrmalian as rsp><rma lha aannov a ahe
eMrJ'nfrhrt rrrr rrl Nat Hearn prrvtdaadro nc�well owner.
r•�oir r ndrr r?f rcllanrkt ac>Ilan nrearlrr bast nflhla jarna. 23_Site diagram or addltlo mal well di=11s:
A-Pfar Geoprabe/IMT or Cursed-1 anp Gelrih m
ermal Wells hAvinq the sae You may use ntc back of this page to provide additional well site details or well
Consinrctinn,nnh t G%1.I is needed. indicate TOTAL NUMBER of"wills construction ddails. You may also attach addifuonal pages if necessary.
drilled:___ nnpTAl,i ' UCTiQNS
?,Total well depth below land surface: 2r) _( •) M. »or ALfth: Submit this form within 30 days of completion of well
Par nadliptr wens litedidiiia.ifnrvferrnr("mnplc-_1@200'ond2@1091 ennstivationto the fdlo►ving:
10.'SIR&water level below top of rasing: (ft.) Division of Water Resources.information Proeess;iu,'IAdi,
l f e aler pear.!t tWw re carin&we 1617 hi1an Service Center,RYleigh.NC 276"-1617
t
1 i_llorehole diameter: V, ( :1 1 (in.) 7dh Far IniectioR Well in addition to sending the form to the addraas in 20
1�Well construction method: 1 -� abDve,also submit one copy of this form within 30 days of eompletlon of well
ct►nsltuctian to the following:
(i c.auger,mtary.cable,direct posh,etc.)
DiWslon of Water Resaureea.Underground injection Contral Program,
r OR WATER St:PPI.V WEi.L3 ONLY: 1636 Moil Service COtrr,iRAtelgh,NC 27699-1636
1314.Yield(gpm) L method of test: %-01 11e. Ivor Witter Suably&iolecHon Webs: in addition to sending the form to
the rAdress(cs) above, also sulmtit1011c copy of Wit form ufttltin 30 days of
t3h.11ts1nfectian type: Amoral completion of tvdl construction to the county health depa..tnent of the county
where Constructed.
Farm M-t North ramlirmDapnnment of l:n imnmmtnl Qamlity-Division of WaW noaameec ' Revimid 2 22-2616

Well Driller Self-Grout Certification
owner: I,, P"V'I �? New Well: L`
Address: ,}M ,x 5 _f 2 L �Ct xe�air:
Permit: ii5''I( Lz I NC
I hereby certify that the above referenced well was grouted in appearance in accordance with
all County Well rules.
WellDaer• C L /
S Signed: �-..-• ._----- .�.
Certificate#: -�0 3 A Date Grouted: ..2V D 1
Construction: Grout:
Total Depth• �1c� 1t-
Casing Type: pvc- Thicimess. n1 i a_� d
Casing Depth: Depth:
Diameter: LV
Weight/Thick-
Height:
Drive Shoe:
GPM: 1 U