GW1-2022-01062_Well Construction - GW1_20220107

828-622-7241 P.1
Feb 1519 05:43p Clearwater Well Drilling
WELL CONSTRUCTION RECORD{GW-1) Fnr internal Use Only:
i.
1.7 Contractor Information:
7� 1 " �P �'� �F _14 WATE1tLONES --
--' RRON Tin
%yell Ctnmraour Name it
13- ft.
fr.
• __
VC Well
QC.nn�yrc{an�cr�Certification Numb D t� —i1 QIiTRR CASING for motfl<ated wells OR L(VER if a licabte
�1�- //• �V( PROM tt. tt. D ME7LRin. 'rltICKWPBS MA
I(PAW
Cnmpnny Namc -.. �� ^� 16.INNER CASING OR TUBING rtwrmal closrntt-Ioa
2.Well Construction Permit 9: �� 5 mom T� otAntcTat nrta:ness MAtERtAL
i.l rt all appliveNe well cnnurnctiall pormils(l.a.VIC.County,Stale,Yariaaca,el:.f Et. ft.
3.lWrIl Ilse(check well use): tT. ft. in.
Wa ter Supply well: ^t r.sCRBBry
l7tOMI rA I DIAMETFM f SGOTSIZE I THICKiVgSS I
MA—
Agricultural MlmicipallPuhlic O ft. ft. in.
Geahennal(tieati:tg/Cooling Supply) Residential Water Supply(single) n tt in.
[ndustrial/C,ommercial Residential Water Supply(shared) t&GROUT
Irri^at1On PROM TO MATERIAL smPLACEm9;wrmjFMOD&AMOUNT
iYnn-�1'nter Supply Wrll: T 1•r. ft, n
A4onitaring Rtxoozry ft. fu
in)ection Wctl: -
Aquifer Recharge QG ft. R.
roundwatcr Rcmcdiatioo 19.SAN=RAVEL PACK if o licable
:Aquifer Storage and Recover), []Salinity Barrier FROM TO mATMIAL F1HPUICEMEIVTME7ItOn
AquiterTcsi ClSwrinwsterDrainago tL fit.
Experimental Technology 0Sultsidence Control t► f►
BlEo-ah1=111.1
thsed Loop) Tracer 20.DRILLING LOG attach sd 1a11/ets ihteoesa
ftdm TO DEioCRIVMT4 color.hardsm.waherkt ralnrispsie.)
atin oolinp 11.wm) Other(explain tmdcr 421 Remarks) tt OttRO (/
t.Date Well(s)Completed: �� Well lDN it• c(t. MwkAeY
`James
Weill"nenNnn: -
Jame s N tw cm 1 fit. - sus.
FACilk"'OkinerName Facility[DO(if aytQlicabk� 0' R
2L4 Hughey -
ft tt.
P sirnl Address,Cy','�a(nd�'7►,i^Ql/� ' ^Q(�
� L1.LL15�_ �-1 1�� W V W 2 REMARKS
County Pneeel identification No.QTN)
Sh.Latf code and lonRitnde in dcgreesJminntcs/seconds or dccimol degrees:
(ii well riel9.one is flang is sufficient) 0 1 e firAlioa:
a3 O 155 a coo t512 *Y � � - -�
6.Is{lure)ffir wetl(s) Pa mnnent or ©1Trmpnrary sign a of .enirQ well Contmtaor Date
y.� 1tv.sii.ming iltte.(rrm.I herrhv ertrify[liar the iwdl{..j Nor(were)crmnrttderl in accordance
7.is this A repair to an existing well: Oves or
No wiih 1SA A'C,1C 0).C.0100 or 15A NCAC 07L•.0200 Well Cansrrnenarr 9andarrlc and that o
l"(1)h iv a repair.fill mrrkmwn rvrll4wasiraclimt inrnrmado"mi 1 explain The muurc gfiha tnpy nflh!r recnrri hD.r AM77 pMiti d 16l11r wilt/nwJter.
r•pair under A21 rcmarlrr scrltmt or nn 1/n hark of lih fora. 13.Site diagram or additional well devils:
R.Cor Gmprohe/DPT or Cl(m. d-Loup Geothermal Wells having the same )'ou may toe the back of this page to provide additional well site details or Wei)
construction,only I CTlbr.1 is needed. Indicate TOTAL NUMBER ofnrils construction details. You tray also attach additional pages if noersswy.
- §:IIQiN I.I,NSTRLI[�t,OP15
?.INIA(well depth below land sur_face: ®� (R.) 24% tor WNIs: Submit this fort within 30 days of completion of well
S-Arabiplr Nrily lhr all d eplhr ifdi,(ferenr(eranq*-3(n1100•and i r�i 1001 construction to the following:
111,Static water level below top of casing: (ft.) Division of Water Reurt roes,Information Processing Unit,
1J.„ah r lvw!is above raving.me"• 1617 M211 Service Center,Raleigh.NC 276"-1617
11.11onehotediumeter. U y—�(i�n.j Uh.For iwiection WAIII:. In addition to sending the form to die txldraa in 24a
12.W eli construction method' 1 V�. above,also submit one copy of this form Tuition 30 days of complexion of well
construction to the following:
(i a Auger,ratnry.cable,tiirttt ptlslt,txe,)
Division orWater Resources,Underground Injection Contra)Program,
POR WATER SI:PPIA WELI.3 ONLY: t636 Mail Service Center,Raleigh,NC 27699-1636
130.Yield(gpm) c5 Method of test: lac, For Water Snip)}&kiceflon Wells: in addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: coompletion of well construction to the county health department of the county
where constructed.
Vann GU•'-I North C:amlinn Depnnment of lin.imnmcntnl Quality-Division of Water Rayocrcnc! Revisod 2 22 201 F