GW1-2022-00991_Well Construction - GW1_20220107

Feb 1519 05Ap Clearwater Well Drilling 828-622-72.41 P•1
WELL CONSTRUCTION RECORD(GW-I) Far in(emni Use Only:
1.W IlCnntractorinformation:
losiaY u 1 { i o 1 s —t WATER ZONES Well f o-awkior Name PROM Tn DEs RlrrIoN
. 1
VC Well Cnnhagnr Cettifrcntion Ntrtnhei 15.OUTER CASING eor mal(igted welh OR LIVER if a 1lcabie
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rx-A I+RnM m D1A R ' rtCKNESS MATERIAL
l (� ft, f/. ts it in. � /
Cnmpnny Namr. —�' n —16.INNER CASING OR TIrRING therm..etmea too v
2.Well Construction Permit#:�o 1 � Q 1 LO PROM I TO DtAMLTER TAICh1t E55 MATERIAL
i.lsr aN npplirn5lc wc11 cv/nurucr/on pernriLr(Lc.1/lr:.C.nnrNy,Sraic,t•artnncw,crr.J ft. ft. in.
3..yell Ifse(check wel)use):
Water Supp�v Well: 1 Z SC11SEN
FROM iA DIAMt3'M SLOTSM rmicKXM MATERIAL
Agricultural �Murticipal/Public () ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(gurgle) R. fL in.
frAusirialiCommercial Residential Water Supply(shared) I&GROIfr
Irri^anion FROM TO MATERIAL 1PLACBN1E7rt'?1 Oo&&TOUNT
Yon-►1'ntcrSupply Well.. ft• (L
Monitoring Recovery a. ft.
Injection Well:
fl. ft.
Aquifer Recharge Groundwater Remcdialion 19.SAND RAVEL PACK n livable
!Aquifi r Storage and Recovery' Salinity Ranier +PROM To MA TRIAL F1tt►LACEMBttT MLTUOD
Aquifer Tcsl QStormwater Drainage
Lxperimental Technology Subsidence Control tt fr.
Geothermal(Closed Loop) [3Troctx 20.DRILl.1NG LOG att additionalch sheeb feewea
FROM TO DESCRrrrMN ook,harilaw,wWrotk! Irrelee,ete.l 1
Getltttcnnal(Hearin oolin>,Ream) 0thcr(ex lain under R21 Remarks) ft. FL
f.Date�t'etl(s)Completed: —^ Well IDN ( (/� ft. 1(t. i
Su-Well Lnradnn: �t ft' ( aA,
eft. LA
r
I acilih"hiller Marne Faality iDif(ifapplicahir.)
Ph O'Cal Addreas,City,and Zip r o "I'd (L
C 1 IV ,21.REMARKS J!"tIV -
County parcel idemitieation No,ON)
%.Latitude and longitude in degrees/minutes/Seconds or decimal degrees:
(ifwcll fic1,one latgeng is sibmeiart) p
� 1 t 3�. J V :2.Cetti anon:
W V �/
6.Is(arc)the well(s)PPermnuent or ©!Temporary S' rise ofCentaw well Ccmtmetor Dme
sliming rhLv,;ern,1 herrh.v crrtlfy Choi lite iwdl(a)war(x e)ermsrrrrni d in accordance
i.1s this a repair to an existing well: E)Ycs or No ndrh 1SA.4Y.'AC.'02C.0/00 or 1JA NC.AC 02C AN10 Well CAnslevoton Momlardr mid ihin a
T111iVisarcpoir.,iHarukMan 6r,rw1in'eA(1hu cnPpgflhftrecorelhoc•hrcmprotidedto the well Airier.
m,00ir under t,2i remarks se:nr)e ru'oa1/n:hack nfthlz.�rrni.
23.Site diagram or additional well details:
R.For GeoprobUTfPT or Closed-Loop Geothermal Weill having the same Vou may use the back of this page to provide additional well site details ar Weil
censinictinn,only I GW-1 is needed. Indicate TOTAi.NUMBER orvmlls constructio l details. You may also attach additional pages if necessary.
drillul•
rJOs 11 .> MnTAl.IN1;'fRJ1CONS
I'"""O l(well depth Irehnv land surface: ,( ) yta• r'or All Wells: Submit this form within 30 days of completion of well
Far nruiliplc x•rll.c life Ali d nticr ifrf�cnmt(riarro/u 3(g1100''\and 2@I001 construction to the following:Ill.Static water level belowtop of earlerg: V _ _____ (ft.) Division of Water Resourees,Information Processing Unit,
1/'xnhrrirlrc!isrrJvroacaNng,rear"•�' 1617 fMafl Service Center,R>ileigh,NC2?699-I617
t i.Borehole diumetcr: I (in j 2.1b.For Inlerio,R Wells: In addition to Sending the form to the address in 24a
12.Well constntetion method' 1 tJ a y1 almve,aLw submit one copy of this.'form within 30 days of completion of we11
(i c.mrye^,mtaly.dthk,dircet posh,cle,)
T-- construction to the following:
Division of Water Resources,Underground injection Control Program,
FOR WATER SI:PPF Y WELLS ONLY: 1636 Mail Service Ccnter,Raleigh,NC 27499-1636
138.Yield(gpm) Method of test: _ 2ac. Isar Water S n v&Foleellon Wells: In addition to sanding the form to
the addresses) above; also submit!onc copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where ctirtsenrcted.
Donn GW-1 North Carolina Deportment of timiroamccml Quality•Division of Water Rosairces '' RevisoA 2 22 Zan 6