GW1-2022-01021_Well Construction - GW1_20220107

Feb 151905;43p Clearwater Well Drilling 828-622-7241 p 1
WELL CONSTR117CCTION I ECOF&(GW-1) For Internal UseOnly-,
t, Cantrair(arinformation:
S i4.W EREtITtES
(mo s ro DMIUMON
Well Contracux Name ft ft.
VC W0 Cnntranppnr Codification N,Mber ' ( s•OUTER CASING for maid-aced wells OR Lt?IER Ifs licebte
WLU '�.J, " 1. I�OM TO. DTA R 'lilt P�.S MA1 L
it. ft. 01 y in. I MID
Cn np my Name {-� t ,UYNER CASING OR 711111ING tfiormd erased-too
2.Well Construction Permit 9: Q gat) 7 �1*ROM n► oust Tntct:Nrss MATCRIAL
idw al!a/q hoOle well canrrnrdlmr y rmltt(La.Ol(:,Crernfy,S!alc,Yurtancu,cm.) fl. IL in.
3.NMI Ilse(check well use): ft. in.
Water SupplyWcp: MA6RU
t�sCR6Ery
FROM TA DIA CTM BLATSME TNICIQM58 L
Agricultural E]Mtmicipal/Puhlic ) p, ft. in.
Geothermal(lieating/Cooling Supply) Melidrubt Water Supply(single) in.
Industrial/Cornmercial J3Residehtial Water Supply(shared) 1&GROUT
IRi^atlOn FROM 7 MATERIA aprPLAC C. Mr•.TLtODhAMOUPI7'
Nnn cr Supply well: fr, AU
fr,
Monitoring Recovery it. fa
injection Well:
ft. (L
Aquifer•Recba%c E3Groundwater Remediatirm 19.SA[�lGRAVfiL PACK iEa lieatle
:AquifLr Storage and Rcrovcry []$atinity Barrier A SA TO BIATMAL t11iTLAC MB T MC7'ItOD
AquiferTcit ©StnrtwaterDrainago n- b.
Experimental Technology [JSuhsidcnme Control �• n
Geothermal(Closed Loop) �Traccr lk.DRILLINCLOG tdlacbadditi alstttettiiftneoessa
PROM TO 095CRIPTMN eaMr.han'dnaa roWrockt raMeise.etc.)
Geothcrtn.1(Hcatin ooling Return) Otber(explain under R21 Rcrii i-s) tt. RTs- . a (/
4.Date�t'ell(s)C.orrtpjCted:q` ?"Z� Well IDII fr. 301 it. ( tc
Su.Wc111_ncatinrn• 3,vc Qc_�'D&
�Icild)'(hlr+etMone ... Facility[Dig(if applicable) R• tL
11lJJL P.Nysi'cal
AAdracs,Cityand Zip ft0q 0� 2t. ARKS�w3( ✓ ?
Pnrwl Identification No.QN1 -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Wwelt field,one lntgong is sufficient) o r C rti cation:
6.ls(arc)the well(s)�Pa•manent or ©ITempnrary Signnl nfC.ertifed Well Ctmtmctor late
` !tv staring#11&.fiorm,I herrhv cxnify rant floc iwdl(%)tar(iren)amorwYed+n acuordivice
7.i,this a repair to an existing well: :)Ycs or No 01h 1SA.t!'AC'02C.0100 or ISA NCAC NC.0100 well(:',nrtrtmtrrrn Sfandardr mitt+hat it
J,+'lhrr i..o repoir,,�11 ourknakn rv+Jf,asctructlnn infarmarian arvl crpinir,the W11're.nrrha ropy nfllrtr rctvirrl AoF hvs2f prodded!h!/te tvCil mvt7tr.
r-, jr under i,:f remark+.rccami or on dhc harp nfiloh form. 23,site diagram or additional well debits:
9-Par Geoprohe/DPT or Closed-loop Geothermal Wells having the same 1'ou may use the back of this page to provide additional well site details or Well
oentilntction,only I GA'•1 is needed. Indicate TOTAL.NUMBER ofwrlls construclion details. You may also'attach additional pages if noeessttry.
drillul:�__ _
.(`IBM UZAI.1r$TRT ICTiONS
9,irntal well depth below land surface-.. ��(11.) 21n. &r M1 Welts: Submit this fort within 30 days of completion of well
Far nodtiple xel/e lirr all a rplltr jd derenr(rrarnole-8@I00'oad i rt.10o) construction to the follotting:
to.Static wattr level below top of tasing: (ft.) Division of Water Resources,Information Processing Unit,
//'xnrrrlc+c!lr+rhnvacnong,vtc"•"tI(x� 1617117ai1 Service Center,Raleigh.NC276"-1617
l L Borehole diameter. � (y \(in.j 24b.For 1nieetigEl AR111: in addition to sending the form to the address in 24o
12 Well construction method: { y� abrne,also submit one copy of this form within 30 days of completion of well
(i e.ougc,rotary,atbk.4ir"'t push, cnnsftuetian to the following-
C.
Division of Water Resources.Underground infection Contra)Program,
POR WATER SCPPLY WELIAS ONLY: i636 MailServiee Center,Raleigh.NC 29699-1636
13a.Yield(gpm) I Method of test., lac, lior Water Supply&Inject!on Wells: In addition to sending the fbrtn to
the tlddress(cs) above; also submit One 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 consltucted.
1+nrnt CVr'-I North Qamtina r?epnnmcnt of tin.ironma al Oaatity-Aivismn of Wahl Rasaarc�r` Revised 2 22-2016