GW1-2022-01010_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 p•1
WELL CONSTRUCTION RECORD(GW-U For internal Use Only:
1. !'.ontraetor information: _1 _
S WAT LOVES
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N"Wct)Cnn^tracioiCatificationNumher 1 , 1 1 • KOUTFitC INN format welt OR 1fa imbit
1 '' 1 `/ /� W D'I 1 1 IntOM fC. M tl. DtAM'E'f R 7a. TH C IRS 4ATFAL4,L
Cnmpn�nyANa\mc/1 ( \y C i 1 ` 16.INNER CKSING OR TuR G tttprmal elcaed400
2.Well Construction Permit#: .�� �TIR034 1 To DGMCiEa art S MATERIAL
Lkl nN up/dicolle well mn.rrntctinx persriu ry.e.!/K;,C,anMy,Stale,trarMnncc,err f it• k. in.
3.1Velt 1(Se(cheek well use):
Nato 5npplg tiYcll: U.SCREEN
Agricultural [Mtmicipo public o 0- TO a. nrAMErFat st�oT Trric ass ATaaul
Geothermal(1•Ieating/Cooling Supply) Residential Water Supply(single) ft. it in•
industrial/Commercial Residential Water Supply(shared) 1R GROVI
Irr( ROM ? M TEIUAL rMp&AC s M. D&AMOUNT
Non-�1W'ntenfer Supply Well: tt. fc
�4onitoring1311ccavery
injection ell:
- ft. R.
Aquifer Rechstge ©firoundwotcr Remedialinn
-Aquifer Storage and Recovery f3Salinity�Barrier J�IG—T4) PACK rV A lfcable ®ttrtwCEMBhTMCTlioo
Aquifer Tcst [Stotmwater Drainage rL n.
Experimental Teclmology [Subsidence Control ft. R.
Geothermal(Closed trap) [Tracer 20.DRILT.INC LOC fidtnch additional shavis ifnceessa
FRox To D x ahitrrlam tewroe r . raMriu,eter
RGeothermal(Hcatin oo[in Retains) 0tber ex loin under 1121 Remarks) re. to rjr
4.DattWetl(s)completed; lIWc111D# R. %
'+a,Well Lneatlnn: fr. &
111�V�A1�-11 JA -br� ft. N.
rh: Faeility[Dil(iftgtplicaMc)
i V6 ' IV R. R. _
Ph .nl Address,Clty,and Zip It. �
1� ARNlC
Caumy 1 Nifeel identification Not(PRS)
Sb.Latitude nod longltudt in degrees/minutes/seconds ordccimaI drgrecs:
OeWell fieid,one lattiong is sunicic t) p t ;12 C rtifieAtion:
b.ls(arc)the wcll(s)0kPcrmanent of [f cmpnrary
777 5ipn urc f Cettfiat Wdl Cantmctor e
'��� by a!).ming thls 1ii m,I herohv arr/ffy thol nce sell(..)was fvm,)or4witan4rl in occnrdmrce
i.is this n repair to an exisdog wall* Oves or P +a loth 1SA.tiCA('02C AV00 or 15A XCAC 02C.'.0200 Well C:onxln,rnrnr SlondartLc turd Am n
011A isn rc/tair..�)1 muknmvn nrll.ronarnrtinn i7fnrtwlion arrrl explain!be nanne nfthe enm nfiltst n'rnrd Mr hMlr praitirJetf Ip 11•e wdil nwriex.
revair ander&21 remark.T uromi ar na Ilte hark aflhh form. 23-Site diagram or additional wall details:
R.For Geoprohc/DPT or Claced-lw►np Geothermal Welts having the same 1'ou may use the back of this page to provide additional well site details or%vJI
enrosimetion,only I GW 1 is needed. Indicate TOTAL NUMBER of uclis construction curtails. You may also attach additional pages if locesstry,
drilled!__.—`—" �;�III�!'i�'AI.1itiST'RIICj•FUNS
9,halal well depth below land surface: '__ _(!t.) yb• For Ali Wells: Submit this form within 30 days of completion of well
Far nraltiple Wedc lilt 011 d,pthv j(dii feriw(example-d@SOOT and i 100) Comirardon to the folloleing:
10•Statie water Level below top of easing: O (R.) Division ofWater Resourecs,Information Processing Unit,
IfMahrlurc.A'nlvtr±twrlrtg,the 1617141ai1 Service Center,Raleigh,NC27699-1611
11•Borehole diameter: 8 (in,j Ztb,For Inkclion Wclls: ID addition to sending the form to the addraa In 24a
12 Well construction method: 1 V above,also submit one copy of this form within 30 days of completion of well
cnnstruetinn to the followin
0 C.0139C7,MM. %cable,dirttt pitch,
FOR WATER St:PPI.Y WELLS ONLY: Division ofWatcr Reaoatres,Underground Injection Control Program,
1636 Mail Service Center,Ratc4h,NC 27699-1636
13a.Yirld(gpm) I 111ethad of test:�� 24e. For Water S�Faieclion Wells In addition to sending the forth to
the address(es) above, also submit one copy of this font widtin 30 days of
13h,01sinfection type:,- •Amount: completion of well construction to the county health department of the county
where constructed.
I•arnt OW-1 North Carolina Dcpnnment of L'n.irunmcntnl Qna•ity•Division of Water Rcsmtmes Revised 2-22-261 F