GW1-2022-00885_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 P''I
WELL CONSTRUCTION RECORA(GW-1) For inrcrnal Use Only
L C.ontrattor Information:
\W'S 1 9 iic W T ZONES
well Call mix Maine nn°K To nes wrtToty
VC:W'e11QCnntmeloor.CMnificati(o�n�Ninnber I&0UTFR CASING forTn jt1 edwells ORI.I. ifs t!!4
n I+ROM i'A D1A R 'tl t E.. 14ATML L
tt. 0- in.
Cmtpnny Namc _
Z �o�1 f1YNf R CASING OR Tlte1NG ehorm>tl c -boo
2.1Ve11 Construction PetTn #:il /�� jj 6 tntrR o TO n1AME1T.A I •rntcw-trtss I wA'rgarAL
i.l.rt all npplirnllr moll tnnrentaien permits(Lc.11X:.Conrrty,Stag a. ft. in.
3.Well Irsc(chctk well list): It.. h•
W�tcr Supply WcR: 17,SCREEN
PAWN I TO DiA TM SLOTSUE I THICKNESS I MA BRIA
Agricultural Municipalftblic Q n, ft. in
Creothemuil(Heatiug/Cooling Supply) OResidential Water Supply(single) o, fr
Industrial/Commercial Rsidential Water Supply(shared) III.GROUT
lrri^DtiOa MRO T MATERIAL 04eWCEMCrra1 OD bTOUNT
Non-R`nttrSupply Well: ft R
Monitorin Reca>sry to. fr.
ntection elf:
ft. 0.
Aquifer Recharge Groundwater ttemediation
19.SA RAVEL PACK if¢ iicabl
:Aquifer Storage and Recovery E)Salinity Barrier FROM To MA 1AL II1 tdlCEM11ElVTMCTtrOn
Aquifer Test []Stonnwatcr Drainage ° r'
Experimental Technology [)Subsidcacc Control rL I tr.
Gcothennal(Closed Loop) 13Tracc1 _20.111RUILLiNC LOG fatlai h additional gft ifnecesm
FROM TO DESL'R1PTlOtt cotor.htrd soWnKk r ral"slt goal
CieotGennal fHcatin �IinR R.ca,m) 0tber(explain under#21 Remarks)) i f� re
4.11ateWell(s)Completed: Well ID# L— rt• tf" `/ �`
It.Well Location: ft
�.�n.: i Sh Mft. n.
Facilih:Utner Hame Facility iDil(tfapplkahie) A. AL ' 191
physical Addrec City,and zip Jft �
Jl✓tl�Vl '� 21. MARKS
CotnuY Parcel(dentifieaticm No.(PrN)
SECI ION
Sh.LR III tudc and longitude in degreeslminutesisecaads or decimal degrees:
(if well frdd,one latIlong is suli'icimt) i / :!2.f ertifieatio a rvn
6.Nam)the well(s)&Permanent or ©Temporary Signet • f Cxnifial Well Contractor Dme
Jtv ai OR M&.frrm,J herrhv crrtth:that 1hr twdl(a)tear(were)crnrsrmffed in acwtda.•rcr
7.is this a repair to an existing well: E)Yts or JNo u•ir! SA.Vf:AC.'a2C.OJ0o nr 1SA NC.AC A7C.'.0:00 p'rrt[nnsrn+crinn Slat rlardr tort thm a
(JOdi is n rcpoir.fill narknotvn 1,41f oonstmairm inrormalion and crp/rnn the antore nfrho tnptr nJllrfr renird haehrem pmtdde f 1n tlx w rll nwrur.
raoair under G2l rcrnnrkc SrXtlett tr/'rM 1Jh�Aar'k oflhl�(nrnr,
23.Site diagram or additional well details:
R.Par Gcoprohe(DPT or Closed-Lonp Geothermal Wells having the same Vou may use Ilic back of this page to provide additional well site details or well
onnslmctinn,only i CrW-1 is needed. Indicate TOTAL At.NUMBER of�vT lls cotlstructirm drtails. You may also attach additional pages if necessary.
drib{ul:
��
l�nrruuhiplc b,(� TR MirrAI.INSUC MNS
9,,fatal well depth below land surfuca 2,i..t, rar All Wells: Submit this form within 30 days of completion of well
>.rllstirrafid.�/lasifdiffenmr(rtmnple-3(n�IgO'a»d�lOD� cnnstructiontntbefollo►eing:
l0.4tat)e water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
?J x ahrr fecel lr vlvrva casMg,uur'•"1 16171Man Service Center,Raleigh,NC 276"-1617
1 L Borehole diameter: � I� (in.) 21h.Fnr Injection Wells: In addition to sending the form to the addrm in 24a
17.Welt construction method:_ I(�liVl�{ above,nlso submit one copy of this',form within 30 rays of completion of well
--1--(i c"nstruetion to the fotlowing:c.nugc-,coact,er>l+k,direst mtsh,cKt.1
Division of Water Reaources.Underground injection Contra)Program,
FOR WATER SI:pPI ti'IWFL S tNyLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: � 24e.For Witter Supply At falecHon'11•'ells: In addition to sending the form M
the address(es) above, also submit one copy of this form within 30 days of
tab.Disinfection type: Amount: completion of well construction t"the county health department of the county
where constructed.
Form OW I Worth C]amtinnsacpndment nflinvlydnmcrtnt Qaalisy-nidstnn of Water Regonreaa Revisal2-22 201 f