GW1-2022-00921_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 PA
WELL CONURUCTION RECORY.)(GW-l.) For inicimni Usc nly:
I.Wtll l•,nntraetor Information: 1
1 � Y K W TERLUNES - -
tVr1F(rntdaatx Name tntoN To DFSCR1rTrots
ft.
tr.
NC:Well Cnntm for Certification NAnnber (y TITER CASING for molflgsed wells OR Li?lER if a lhaeble
��'�a�� MOM TO DIAM1IETLR 'r11IC7LNESS MA]'ERUL
Company Nama ^� /� -16-tNNER CASING OR TUBING thermal clmeditw
2.Well Construction Pertnit a: �oll v ��ta0M 1 TO f oIAMJLL R TRICIKC S NATEarAL
i,fxt MI alytlicn9la 11,91/rnnwnr41ia,p:rmrtr(l.c.(!1(I Cnnnty,Stale,Irartanrc,rh,J ft. ft-
3.Well ltse(check well use):
n. I (t. in.
Water Supply Well: 17.SCREEN
mom to DIAMt3'ttt92 SLOTst¢E THICtCN MA7ERfAL
Agricutt(Iral Mimicipal/Puhlic (► R. ft. in
Geothernlal(1•leating/Conling Supply) evidential Water Supply(single) ft- fL in.
(ndusirial/Commercial Residential Water Supply(shared) 1&GROUT
lrriWnfe FROM T MATERIAL EMPLAC EVI'M, 13 AMOUNT
iYnn-13'nler Supply Well: tr. fa
[!Aquifer.Storage;
toring Recovery ft. fr.
n Well:
eu Rechatc �Ciroundtvnter Remediatinn fl. R-
19.SAN=kA.YEL PACK [a licahlc
and Recovery [3Salinity Barric, ROH TO 41A I L FlttllrlCEMENTME7710er Test ©Stnnnwater Drainageimental Technology [)Suttsidence Control ft.ermal(ClosedLimp) Tracer 20.DR1LLINGLOt; atlachadd aloheetsifnts:esMoFROM TO nE5 N tnlarherd ae.rauhmkr , talntiw.cte.l
crn/al(Hcatin oolinR Rental! gther(ex lain under k21 Rcmllrs} rt. fr
.4-DateWell(s)Completed, L'� "Z Wcll my ft. it.
Su. ell .nttitMn ft. (t. i •
( a -
P:tcilih:'(lnv,cr?lame Facility IOW(1fafuplicaMr)
v!iml Aedres,City,and 7.ip �! ft. R. 7 ?
/lt_ !// NJ'dj `/d lJ 21.REMARMtS
County Parcel(den itieation No.(PRdI
Sh.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ii well rreld,ore Iati^longj s s�uil�icicnt) r Q p t l I :!2. erti cation:
J
6.)s(arc)the wtll(.$)OPermanent or ©Trmpnrary Srgnnhirc n Certiriat Weli Can ctor !Date '
Jtv s4'"ing 1110 j,t•m,J lrrrrhv ceRrtji:Runt Rhr uult{.)war!were)crxutru 1M in a vordnttcr
7.1-1 this A repair to an existiag welt: Dyes or No M+th 13A.'l'CAr.•07.0.OJOO or 15A NCAC 111C.'.02110 Welll:onslrr trtmr Vandardr ant that a
J,t'Ur1r is:>rc/toir.,pll aurkanun nvU ronsrrnctrnn infnrrnat(o,and captain 16r.nanrrc q('rhv tops,gfdrfc ri-eted has deer proisded Jo the weft ntvner.
r•.�air wider i•11 rtmnrkv.rcrrimu nrnn tin:t,r•k nj tlin fnm,.
23.Site diagram or additional well details:
R.For Gemprohe/DPT or Closed-Lump Geothermal Wells having the snale You may use the tack of this page to provide additional well site derails or well
txmslnlction,only I CrW.I is needed. fndicWc TOTAL NUMBER oi-N%rils construction details. You may also attach additional pages if necessary.
duilh:d:
f),V431a1 well depth below land surface: :I O tJ ,(R.) 2,m. for Ail WNis: Submit this form within 30 days of completion of well
rear MUNF/c e•ckc&I a1i d nllw 1:fdii fererr Cciamole-3Co1I4n'oad 2@lno) construction to the following:
I0.Static Witter level below top of easing: (ft.) Division of Water Resources,Information Processing Unit,
%aak,•laro,iaahnvrcaang,One
t 1617 Mail Service Center,Raleigh.NC2'/699-I617
l i.Borehole diameter. Zfb.For Ialeetian Wells: In addition to sending the form to die address in 20
I Well constnletlon msfhod: T above,also submit one copy of this form within 30 days of completion of well
(i , construction to the following
C.Auger,rn tu}•,altk,direct push,etc,)
FOR WATER St;PPf.v WELLS ONLY: Division ofWater Resources,Underground injertlon Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:J 24e. Uor Wi ter.Sunn1►&1RlecNOn Welts: In addition to sunding flit form to
the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: Amount: completion of%veil construction to the county health department of the county
where constructed.
Dann 6W.I North Cnmliaa 0cpnnment of Ell'irontucntrti Quality-fTivisu,n of Witter ltesanrcec Revixal2-22-2QI6