GW1-2022-00927_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 82M22-7241 p•1
WELL ON RRUCTION RECORD fGW-1) For internal Use Only:
1,Wei lICintraacctorinformaltlnon�:(�(�(� C 1
l / L)h l Y li I 11 1 L J T K WATER ZONES -
Well Centradtx Name PRO." in Pascal N
II. fL
vC w II Cnmranor Ccct;ficAun Number s.OUTER CASING far multi-wed XMJbOR Lr?IER ifa irabte
%mom TO DIAMErLR TUt IDS MATERIAL
in.
Camp lay Namc �� � ���� 16.tNNER CASING OR TURiNG tharm111 elosed•l
2-Well Construction Permit V. �y�\p FROM I TO nuMLTEA I Ttttewtvrss HATsRIAL
i.irr 1711 npplirnhle wall rnnnnfdian p:rptitr(fr.IllC.,Cnnrary,Star,YaNrmce,etc)
D, I h- I in.
3.Well lisc(Cheek wdl use):
n. ft. in.
TVaterSHpplyWell- t2.sc elv
FROM I TO I DIAMETF3t I SLOT.WE I THICKNESS MATP.AIAL
Agricultural fvltmicipaUpuhlic O 4t, ft. in.
Geahermal(1-leating/Cooling Supply) Residential Water Supply(single) R fL in.
Industrial/Commercial Residential Water Supply(shared) 18 GROUf
Irri at10n M TO MATERIAL EMPLACpMElRMMOD&AMOUNT
Non-Wnter Supply Well: ft �
Monitoring Recovery u. fr.
in)ection Wcl:
Aquifer Itechiure QGroundwntcr Rcmediatirm
.Aquifer Storage and Recovcr Salinity hairier o�ND/GRAVBL PACK M&TJMIAL
licablc HttirtwCEMBNTMETuon
Aquifer Tcit T]Stnnnwater Drainage ft. n.
Experimental Technology QSubsidence Control fL h.
Gcothe mal(Closed Loop) 13TCacct 20.DRI[,L)NC LOG stta sd o d ftteeetaa
FROM T D H rotor. rlaes,wttfroc4t ratnaks,etcJ
Geothcmtal(Hcatin oolittR Return) Other etc lain under 921 Rcmarlrs) tl. fe
A.Date Well(s)Completed:�a:1 l Well ID#
Well Location: l ft. 1 I R. )1 �.�-,O i't. R. r/�► ^/�+y
P::eilit);'[Saner N o n Facility foil(ifapplicahle) n• B. Jt _ f i I
PhIyS/irnl Add H.City, Zip rL R. JA
�� 21.REMARKIS
County Poteel identification No.(PIN)
3h.Latitude and lonkltude in degreesiminutes/seconds or decimal degrees:
(dwell field,one IaMong is suifleicnt j Certifi on:
i--
6.)$(arc)thewell(s)t4Pcrmnneat or ©Te.mpnrnry Sign of Certified WellC.mtmator DrAe
n ins 1100 lilr•m,I h►.rrhv e.a7r/fj:that rhr 1WI1(.)Imr(tram)rxrnorwyavl in ararlydartc'e
7.la this a repair to an existing well: �Ycs or No t'itl 1S.!47;'X!02C.0100 or 13A NCAC 07C.'.0200 Well Cunslrndlnn Slandardr oral Am n
1J'fhir i.n-Mir..(!l1 olrrknawn u-4,11 a urwalmlOfnrmalloo antierp/nin the nmnrr nrlho eMIY afi tit rcr'rw1 Aar hten prot5ded 10 the will!nuimr.
w,wir raider 01 remarks senior ur mi dw hark of thh form.
23.Site diagram or Additional well details:
A-For Ceoprohe UPT or Gflsed-Lnnp Geothermal Welk having the saute Yaw may use the back of this page to provide additional well site details or Weil
txmstnlctinn,only I G\V•1 is needed. lndicato fC)TAI.NUMBER of wells construction details. You may also Attach additional pages if necessary.
drilled:
`►.Tatal well depth below land surfacer /> _(R.) 24a, ror AH W_tils: Submit this form within 30 days of completion of well
l"rr arubll.Ie Weer 1A,all dopflar fdii ferert reramo/u-on 20(rand 1(nZ100� ennsfitG.ion to the following:(ft)
10.Stacie water level below tap of easing: . Division of Water Resources,Information Processing Unit,
II N•QL'/•/rlV!.IS171VIVrLYIHn�„IGC`'., 1617141ail Service Center,Raleigh.MC274"4617
1 I.Borehole diameter, t` O (in.) Ztb.For Iwlection Wells: In addition to sending the form to the Wilm is in 24a
I2 Well construetlon method• shove,also submit one copy of this form within 30 days of Irntnphnlon of well
0 C.angc,non ..r,*Je,oirett push,etc,)
construction to the fallowing:
Division ofWater Resources.Underground injection Control Program,
F1UR WATER Si;PPI-V WELLS ONLY: 1636 Mail Service Cenmr,Raleigh,NC 2709-1636
13s.Yield(gpm) Methad of test: 2.Ic. Uor W to Supply&Fgjsetlon Bells: In addition to sending the forth to
the address(cs) above, also submit: one copy of this form within 30 days of
131).Disinfection type: Amount: Completion of well construction to the connty health department of the county
where constructed.
Font 6W.I North Camlinn Dcpnnment.tf 1in.9ronmcnt•il gnafity.Division of Water
Resource.—Revised 2-22-20I6