GW1-2022-00887_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 p.1
V1/ELL�ONSTRUCTIUN IZF.CORD fGW-1) For Internal Use Only:
1,Wc11C.nntraetnrinforatation: C
fir, pl�� �n s I WATER tt1NES - -
tv(ell enntraatx Name M," gn DESCtttrrtoN
/VC�Well�Cnn/tr�agnr Certification 6hlrlmt�Kr /� ,�/•� -1,Qt>TF.R CASING armulti cased walla OR LrN= Ira limbtit
I Y (/ / p t/ft ��'1/1 .iif•per• 1 I �l/f[) 0 1 1 N �l`t 933 'ROM M DIAMETER 'rll[f�OIPBS MATE)
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Z _ -•l f'3 (-/)-I t I t Id.MER CASING OR TUBING th9rmnl clnteddao
2.Well Construction Permit#: Z+ G c7 L `mil o>t I TO I DIAMEL I THICKNESS I MAMgIAL
1.3.0,7l1 npplicablc t�rll mrmrrrtrdioN p✓mlfr(1.a till:Cnlrrdy,Stale,trarlame,ci ) - Ef. rt. in.
3.Well U-ic(cheek Ivel)use): fr. R. in.
Wa to Supply Wcll: 17.SCREEN
mom I M DIAM1rM SLOT SIZE THICKNESS MAr6VAL
Agricukural E)Mtmicipalftbiic () B, ft. in
Geahcrnml(Fleating/Cooling Supply) residential Water Supply(single) IL to In.
41dusirial/C,ommercial El Residential Water Supply(shared) ISL GROUT
Irrigation KROM TO MATERIAL EMPEAMMU T M ROD&AMOUNT
Non-Water Supply Well: _ tr. "- r
i 1onilonng Recovery
lnjeclion Well: -
p. R.
Aquifer Recharge Qfiroundwatci Remcdi3tion I9 SAIdiI/GkAVSL PACK raw hie
:Aquiferstgrage:and Recovery Osatinity Barrier -PROM I TO MATERIAL I ERIPLAC MENTME'i'HOD
AquitcrTcst ©SmmlwaterDrainagc
Experimental Tcehnnlogy [3Subcidence,Control
R eothermal(Closed Loop) [3Traccr -20.DRILLING LOG allach addithmalsheets fneema
Geothermal
Mcatinwropling Return) Uaher(explain under#21 Ri s) FROM To DE5 N colar.h.riam,.OU/Mk t ,act Sim ctc.
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.4.Dau Well Completed- I�I a',Well IDtI tt, tL
Su.Well Lorntlnn: W
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F.tcility'(lur,crr tame Facility[Do(ifalipricahle) n It.
G JaAk eAA Uird
Phvsirnfir1,'and Zip —7 h. R
Al.rsEMARKR
County Marcel Identification No.(PRS)
Sh.Latitude and longitude in degrees/mimites/seconds or decimal degrees: -
(ir well field,one latgong is suiticicnt) 011
„2.Certificntipn: `
Q35" l � � �S(f1 31 Div ��fF D`4kSEt
6.15(am)the well(s)RPermanent or ©ITemporary Mpnniurc ofCcoirml Well Contractor I k2•t
try s4-nin1;dde.i,rm,1 heals vwltr:Thal rhr anti(.)way lwermJ crm mulled in aemrdance
i.is this A repair to an existiag well: Oves or 16No «•.rh 1S.t A'f',tC tt2C.0f00 or 1 SA NCAC O2C.'.01110 Well Crmslrncnrn Vanrlarrlr ami 1har a
;"ildr is r rrPair.•ly mrrkmaw t'X eorsrractian b?formaNnr and arplair,the,munr nrlha enpl,411i t ret i)rd hae hPm prmgded 1n 1!L wall mvticr.
mwir under A21 rcmarkc.rcrrrarr or on 1111:hack nflkix farm.
13.Site diagram or additional well details:
R.Por Genprohe/DPT or Closed-Loup Geothermal Wells having the same VOU may use the back of this page to provide additional well site details or well
cx?nsinrction,only I CTW.I is needed. Indicate TOTAL.NUMBER or..ntls construction Retails. You may also attach additional pages if neicessary.
drillui: _
(1BM1V.A'IIN";_MUCTIONS
9,TOM well depth below land Surfacc: �t� _(R•► 11% rjor all Welts: Submit this form within 30 days of completion of well
Par n,ulliplc x•rli.r titr ali d rprlmv ldij!crerr(ciamrr/e-3Cg)100'and i r�i 100 j construction to the following:
IA,Static water level wlew top of casing:,-__ (ft.) Division of Water Revourccs,information Processing Un)t,
ll'«nt,v kw!1s nlvlva ca.+la1,rm c"•" 1617 Ailat7 Service Center,Raleigh,NC 27690-1617
1
lloreholediameter: i �.j/� Uh.For Injection We11s: In addition to sending the form to the address in 24a
1Z.Well construction method: M I a)u a1mve,also submit one copy of this form within 30 days of completion of well
(i c.im c-,rotary. construction to the following:
8• tuy.ashlc,4ireci pt�sii,r%e,l
CiOlt WATER St:PP1 Y WELLS ONLY: Division ofWater Resources.Underground injection Contra]Program,
1636 Mail Service Center,Raleigh,NC Z7b99.1636
13a.Yield(gpm) Method of test: 24C. for N'atcr Supply&faicefloa Welts: In addition to sending the torn to
the address(cs) above; also submit one copy of this form within 30 days of
13h.Disinfection type. Amount: comptetion of well construction to the county health department of the county
Where constructed.
Pnrnt(:w'-l 1Jonh Cnmlinn f)epnrfmcnt of lin.ircinmcrml puatrty-I�ivisurn of tVater Rn«ourcac ReviseA 2-22 261 b