GW1-2021-04149_Well Construction - GW1_20210823

828-622-7241 P.1
Feb 1519 05Vp Clearwater Well Drilling
WEI:L.CONSTRUCTION PECORD G-W--- l Fnr Intemni Use Ott1Y:
1.W 114 antraetor information:r'ie `
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.W Writ Cnntrador Certification Nimncer 1?•t)OTTsR CASING maid diced ORL A r
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C A-.npnnv Name �t6.INNER CASING OR TUSING thorraal t
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?.Well Construction Permit M
0.0 ali applicaAle well Cnnsrnrelinn Pamirs got UIC,Crnrary,-vials,Narianca,cl&)
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3.11'ell ifsc(check well list):
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AsriculturatMttnicipDUPuhlic rt• f1- '"
Geothermal(19eating/Cooling Supply) Residential Water Supply(single) p IL
IndusaiallCommercialResidential Water Supply(shared) 13 GROUT .
q MA'r�R►At 6MP1.Ac `tT)ttcRtO[I&AMOUl1r1'
i171^Dtion l ft, ". R•• jl ',j t .
tVnn tYnter Suppiv K al: l
Monitoring Recovery d, fa
Injection Weil: ft. R.
Aquifer Recharge E3Groundwotcr Rcmediation 14 BAM1/GRAVBL PACK f bie
.At)Ltil'�K Stpra�C raid RCcovel), Salinity Barrier L FJNICACEPIBMI MIG't'nOn
Aquifer Test 0StormwaterDrainagen-
L'•'xperime•ntil Technology [3Suhsidence Control It. R'
Geothermal(Closed Loop) Tracer 10.pRit.T,iNG Lt?rC attach aeedsa
PROM TO D mtoti roaheeEt kraEe,stcd --
Gcothernial licatin ooli Ream) 'other-(explain under 021 Remarits} te. C`t' fL. <'
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a,Date Weli(s)Completed: 2.1 -1( well ID# 5 fr. —lCi r6 C
5_a�.W.r^ll i.nrntinn: ;n• S It t
Facifit}s'(ktmerMarna Facility[Dit(if appltcahlc) _
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Physical Addreas,City,and Zip
r 2l.RFdNARKS {
County Parcel ldemificalion No.QW) •,` - P c� --i(�rt
51).1,Rtitude and lonprtude in degreesiminotestsecondsordecimal degrees: !
%Voll rield,one tat'tio❑g is sufiolcnti u W "Lceirs"tion.
' 355 1 54�S -G.Is(arc)the weil(s) P-manent or DTempnrary Signelurc of(.,cnirma Well Contractor Dt»e
Iry.dlmim;rho.;arm.1 herrhr crAlfy�the)rile IWAAj was hrmz)a wcornctwf in ac rdmrcr
7.In this a repair to an existing well: Dyes or No triNr l S.t 4Y d!`d2C.41t11J nr lSA,Vl AC OIC.'./►1[lO WrhCrwurrncnrur Sramlar f<mrrt film n
I,r'rbisisnrcpoir.fillrnulafnnnnvdl.ronaraellanirtfnrmalinnmr rsprnirtlilt:nature�fnc� copynflhfsrecrxd hog hem prvtidelfln the wcrlenvner.
npoir render A21 re Wkr srclln,i aron IIlc hark of/bh•j0m, 23-Site diaRntm or Additional well detRils.,
R-For G-prohe/11PTor Closed-l.nnp Geothermal Welts having the same You may use the buck of this page to provide additional well site derails or well
mnsmrctirm,only{CTV,r-1 is needed. 1'ttdfcato TOTAL NUMBER nf�vclls construction delaiis. You may also attach additional pages if necessaty.
drilled: UMMILEALMIIram
9.Total well depth below land surface: 8 0 _(R.) Ma. For All Weltg: Submit this form within 30 daps of completion of Well
1%nrn1ulliPirweas1At.1id.:pa't jf&ff"r rrrramnl c-9n1n0•nnd�ir innl cnnsinwA,imito the 10110%ving:
10.StAtie water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
11'a•nlrr&•re!la•abnwc raging,ate(( C•'•}` r 161T14W Service Center,Raleigh,NC2'7b99-1617
ii_Borehole diameter: 4 ( (in.) 24h Fnr Iniection MYeils: In addition to sending the form to rho addrm in 240
1 A Well construction method: l .'L l,l above,also submit one copy of this form.within 30 days of completion of well
I C.nu �,m hr � construction to the following
K refs.rabic,direst tsh,etc.)
Division of Water Resour m Uri dergreand injection Contras Program,
IYiR WATER SI:PPJ 4�WFLLS ONLY: t G36 Moil Service Center,Raleigh,NC 17694-1636
13s.Yield(gpm) 5 method of test: Vc.tier Witter SoMft&fnrcefjori Welf In addition to sanding the form to
the address(cs) above, also submit one copy of this form within 30 days of
13h,l)ltlnfection type: Amount.. completion of well construction to the county health department of the Monty
WI NTe contracted.
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Fenn CiW-t Noah Camlinnoepnrnnent of tin itrinmcnmi Quality-Division of Water ltaser:rtes ! Revimil2-22 2R1 R