GW1-2022-01059_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 PA
WELL CONSTRUCTION REC2R- (GW-1) �For Internal Use Only;
1. I Contrattar infortion:
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WATERtUNES -
AESCRiITION
Well Contraclix Name NC:Well Cnntmetar Certification Ntnnts r S.O11TER CASIN tar mot8�ed weft t7R LiNER n liotble
M DIAMETER 'f11rCKHFBS MATERIAL
sGA'�-FLf•_1•e uy L ''t_(,/-fi_."_" ir, 13 E6 �'in.
nmpnny Tla Fie i6.MI ER CASING OR TUBING Itt9rmnl ctosed400
2.Well Construction Permit#: PROM[ TO DIAML'TF R TAICKMS MATERIAL
Li.w all applicable+vc/l conr+nrc+inn parmitr p.e.fl/[;.CPnmy,Sralc,Vartanre,etr..) Et. k in.
3.Well Use(check well use): aL
atoSupplyWO: -
FROM TO DIA SI.OTSmE THICKNESS MATERIAL
Agricultural �MlmicipaUPuhlic O a, A. in
(]cothermat(i'Ieating/Cooling Supply) Residential Water Supply(Single) ft. it. Fit•
Gtduslrial/Commercial Residential Water Supply(shared) Ig,¢ROUT
Irri DtiOn PROM TO MATERIAL txvtPLACEMEYTN s ODd AMOUNT
Nnn-H'ntcr Supply Wdl: R, fr.
Monitoring Recovery tL fa
injection Well:
Aquifer Recharge QGroundwater Remcdiatinn 19 S,1N11/G1tAVBL PACK [a lieabte
Aquifer Storage And]recover)' [3$a[itlity Barrier FROM TO DtA1TAlAL flNTLACEMENTMETHOD
Aquifer Test ©Stnrmwetcr Drainage n A.
Experimental Technology Subsidence Control n- n•
Geothermal(Closed Loop) OTC-CA x0.[)KILLING LOG attecbaddititmalatttstts ifneeesa
FROM TO DESCRIPTION color. nLea,w11/reckt ralneiweta
CieotGeumal(Hearin ootiltR Ream) Utber(ex lain under R21 Remarks) to fL
.4.Date Well(s)Com(�plleted: Gt -Q Q1 Well IDfi �'J� R• ��tt' V4-11! �
Su.well Lncnnna: Iv`4 p2u►I cur
c9o.--Io Q*A l cu v�S --
F.icilihs'Ov.ner Hmno _f Facility[Diu(ifaliplicafile.) h' c�
W in "el C� 1,�.� �,I'c S R. fr. ,JAN
P <ival Ae.dress,City,and Zip ft. ft. ^
Comity Pnreel fdentiftcation No.(PIN) ll"
Sb.Latitude Find longitude in de trees/mitultes/seconds or dccimnl degrees:
(if wall field,one latflong is sui ident) O Ce ifecation:
JAN v2(
G.Is(arc)thewell(s) pa"manent or 13Temponry Sig nlurcofOenlficd Well Contmoor Dore
7� lty.rfpming r1Ns/•run,I hrwA.y m7 ih+tlwi/hr twdl(.r)was Ara6j fi-rmrirrrriul facmrAnnce
i.is this A repair to An existing well: Oves or No u•nl+lSA A'r''AL'02['AI00 or iSA NC.AC'02 o2vo ell4anrlrtrrnn,r 1ran.MrdaGanrl+hm':i
;r'thfr!—)repair.repair fill our knnnm uv!/coaarnctinn juror nalion of nin the amure q(+Be tam,nfllt/c rer'nrd har hrm prot'ldrd in the well ifi6ttes.
rrxr/r rmd^►r.21 remnrkv sccgm or on Me hark of th/r fam+. 23.Site diagram or additional well details:
R.For Geaprohe/EIPT or C rued-L.nnp Geothermal Wells having the same 1'ou may use the beck of this page to provide additional well site deMils or fuel]
Wnstntction,enly I GW-1 is needed. indicate TOTAL NUMBER of MvcIIS construction[Ietails. You may also attach additional pages ifnocessary.
9.?furs]well depth tre]ow land surface.. ( `f !(R.► 24a, Eff Is: Submit this form within 30 days of completion of%vil
Far nndiip/e e•rltx livr a/i d pq+r•ifdi11"ererr(rramn/v-3(n110(t'and sraZ/O[1'j conStr uction to the folio%vinS:
10.Static wRter level below top of easing: _ (ft.) Division of Water Resources,Information Processing Unit,
l!aaler prat is'Awe caring.fix"•"t G 1617 A9ail Service Center,Raleigh,NC27499-1617
I i_13oneholediameter- ' 0 (/iin.))� 2 11L For Inlectinn Wells: In addition to sending the form to die address in 24a
12 Wait rnnstrNCtlon method: 1 lJ I I�C.YI�I %illnve,also submit one copy of this form within 30 deys of completion of well
(t a nugc,rotary.cable,diroft push.fxc,)
--�— construction to the following:
t'OR WATCR St;PP1 Y VPF.LLR ONLY: Division ofWAter[resources,Underground injection Contra]Program.
I 1636 Mail Service Cenmr,RAtelo,NC 27699-i636
13s.Yield(gpm) Method of test: K� _ 24c. For Water SuMAY&Faketlon Wtlts: In addition to sending the forth to
the Wdress(cs) above, also submit one copy of this form within 30 days of
13b,Dlsinfection type: _ .Amount: completion of well construction tD,the county health department of the county
where Constructed.
I;nrntGW-t Horst Cnmlinn nnntcntoflinvironmc+:tnl fkP Qnalhy-Divisrnn of Water Rasourc&c Revised 2-22-2DI ti