GW1-2021-04148_Well Construction - GW1_20210823

--------- --- --- 828-622 7241 P.1
Feb 1519 05:43p Clearwater Well Drilling
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%yell Contraaor Name tr, fu
VC Weil Cnntnaoe Ceetifieation Nc"n6a- iS.Oil7'ER CASING r On a IYEATER1At.
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C;ompnnv Name 16.LxNBR CA911YG t7R T1181NG dtprmU ettttteti Io0 [
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2.1Ve11 Construction Permit#: tt, ft.
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IJA all"pplicah(a W11e"nrrntefd"rrParm It,get f(,,CaaMy,Slab Varla"ce,el-)
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3.Well the(cheep wd)tise): 17.SCRe N �tctnt(esa •twrsaur.
We ter SnpplyWell: traotut to soot
Agricultural DMumicipalfthiic () R• a. in
Geothermal(licating/Cooirng Supply) WResidential Water Supply(single) (L
Industrial/CommercialResidcntiai Water Supply(shared) 18 CROlP1
.t•O MA'rb0. L BINrLAC Kr lttirStOD&AMOUNT
lrti�otion ENon-Water
R. t SuppiyWell: ff. f
Munitoring Recovery
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fnlection Well: ft. iG
Aquifer Recharge E3(iroundwater Rcmediation 19.SAN111GR+L�L PA AL
CK 1AC�M
Aquifer Storage.and Recovery U,S:dinity Barrier r_ ntef[ IL
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nnwatcr Drainage
Aquifer Tcst �m
Experimental Tecluiology
Sultcidenre Control
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Geothermal(Closed Loop) �7[accr 20.11Rli LOG am" toRltetice In
Gcotttermal Hearin voila Rearm) Other etc in under#21 Remarks) FROx
A.Date K'e11(s)Completed: Weil 1D# tr.
it.Well i MRIUM' GJ_ft. R, '
Fscilily`Clnmertiamc slily IDif(if:grplfeable)
r4�le ��ICt�"1� � Y ' , �1ti 3
Physical Address,City,and Zip a1
Cani,By panel identiflention No.(PINI 8 a t V
Srh.Latitude and rnnRitude in degreesimimucs/secondstwdecimnt degrees: 1
(ii avptl field one tatgong is su(Tcienf) t
„2- e (ieatinn:
Si@nNruc of Cenificti We11 Commetor pme
&ls(arc)the wells) Permnnent or DiTemtorrr' rarXrv1 In oecmMmrcr
i?u ate ling dits.'arm.1 berrhv tanrljr[lrut rhr,wcd►(xJ KM(Bras)condr
?.in this.a repair to an exisdag well: �Xcs or to v illl 15A r.tC•'07C V00"r 1SA NCAC MC.02(10 Wrll Cbrrsrr"cnon yyyrdarrte rral Thai a
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lrYhir ist)repair.fRI makn"am mil eonsinrcrtan i*rmali"a and raphmr the non re gflhc cony"flirts rccard has.bm pmrHd&rn the wall twmer.
r.,mir raider AN remark.waYlrm oronlde:bard oflhirform. 23-Site diagrain or additional wail details:
1'.xt may use tits back of this page to provide additional well site details or well
R.For GeoprohelilPT or Clued-1,60p Geothermal'Wello having the came coastructinn(irtails. You may also attach additional pages if 110cco ry.
constmetinn,only I M1.1 is needed. indicate TOTAL NUMBER orurclls
drilled' ,_.�_ _--- cntenirrrAX iNiTRtIC'RQ[y$
9.Tatar well dcp1A _below land surface: ft-) M.Fora Wslis: Submit this form,tdihin 30 days of epmpletitm of♦sell
!%ar nevAiple aMllc liar rt(i d.:plrat jdi�ercnr(rsampla-3�Jd(t'aarui MOI eon Mmian to die fallowing:
10."Fitstie water Imes below top of casing: _ `si�% ot.) DiviRioo of Water Resources,Information Processing Uail,
IJ"amtvr(cncllrrrlvrvscasing,we
"•" 161711lafl Service Center,Ratdgh.NC2176"-1617
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1i.Ronehotediameter:�l1 s _Ctn.) 24h.F�iaiectiog Well in addition to sending the form to the ttddtess in 240
alcove,also submit one copy of this form within 30 days of completion of well
I I Well construction method: t �i� Wnstntetion to the following:
(i c."age•,mrtry.sable,direc4 pnsb,sic,)
Divislon ofWater Resourm Underground Injection Control Program,
M, R WATER St:PPI V_WFLLS ONLY: 1636 Mail Service Centrr,RAteigh,NC 17699••1606
13a.Yield(gpm) _ _ Method of test=. C — -- 24c,I r Ytreter &Faiection Wdls: in addition to sanding the form to
the nddress(cs) above, also submit one copy of this form within 30 days of
13h.Disinfection type: ,Amount. completion of well constriction t D the county health depanntent of the crntnty
where constructed.
I
Form Gw-I Notch C.nmlimt TJePnrtmont of lenvininmcnmt Qrtality-f�iviston ot'1Vatcr Rasonteec 1 Revived 2 22-2a1(,