GW1-2022-01064_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 P.1
AE L CONSTRI?JCTION RECORD(GW-11 For Internal Use Onty:
tI ntrat formation-
M wAao J 14.W TER ZONES
rRos+ Tn 11WRIMON
Well Coanclor Nal r ft ft.
VC:Well Cnntrzoor Certification Man..-.. S.011TE.RCAS1Nt+ formolti•wtdwells ORLDIER If licebte
0DDI(Ifn
PROM ro DIAMLT6R IMICKNIISS MATMEAL
T_ ft. n. in, DOC
Company Name —
I6.t1YN8R CASING OR TIrRING ttwrmal clwcd loa
?.lYct1 Constnhction Pet'mit#: y(J '�`1' >raoN To DGMETEA 'rn[ct:Ncss HATERut
OW all oppikfible well ranttgtcrioa permils(i.e.f/1C,C.onwy,Smlc,Varlanre,ct:) ft. fL
3.lYe]l lice(cheek well list:):
"t�.scRBt;ry
WaterSapplywell: aaoir,
bIAMEIEit &rATatzE TtrICKNtLSa MATER[AL
Agricultural ��)Mimicilial/Pubiie O Geothermal(i.•ieatiugfCooling Supply) Residential Water Supply(singly; & in.
Industrial/C,ommercial Residential Water Supply kahared) &GIrri ation ROM MATER[AL EMrLACEMEv. rm TROD&AM1tOUNT
Nnn-Writer SupplyWJl: l ap
f° I ( Q
h4onitoring Recovery ft. fr.
(nitetkin Well:
ft. R.
Aquifer Recharge E3Groundwater Remedialinn
19,SaM1/CRAVBL PACK Ala hfe
..Aquif.-r Slorgge and Rcrovei)' [)$-ninny Barrier _PROM TO INATMIAL F111rLACEM1IENTMET11On
Aquit'erTest 133mrmwaterDrainage n n'
Lxperimental Teehnniogy [:pSuttsidence Contral >«• R
Geothermal(Closed Loop) OlTratei 2Q.r)RILLING LOG aitinch td 00mlsimtsifinecomrvi
FROM To DESCRIt"Wit ector.hardtm,aW kf ine4e,etc,1
Geothermal(Hcatio twling Return) Other(ex lain under R21 Rcmarl:s) ft. I ,`/
Al.date Well Completed: � � Well 109 IM— ft. to
fr. ICE—lit `
Set.well 1-o"nn _
rust t, y� �e
I.Cility; %vtM?lame Facility[Din(ifapplicablc) fl, ft
�oi'(� old �uv► I (� ,�.
Avsicnr nrdrcas,city, a zip n (! _
11 X 3��n O 1/I�V w 1 REMARKS
County 1 U Parcel(Clernifieationn No.(PNI.
5h.Latitude and longittidr in degrees/minutesfseconds or decimal degrees:
(iF%Hell rreld,Qne latQong is sutiicicnt) p t .2 Ce ifieation:
W
6.1s(arc)the wetl(s)k1rermanent or ©rTrmporary tii cafCertirkAWellCrmttnaor Date
an existing
by.%1}miag r1+Rr Jirrm,J lterrh1,rmnify Mal thr twit(..)unr(were)cYmomered is axmda7ce
i.is this a cellar%to an existing wd1: Ycs or Nn with 1SA.UTAC 02C.0100 or 15A NCAC 02C.0200 Well C a0mmaa Slolydae&mrrl rAm.r
l,r•(h!t is o repoir.,fll ma knaKm mW eonsirmurn?ittformallon rnv crplain The anaere gfrhe top),aftlrit rerorel Aar trial p►mioiif In well Awner.
r.?,7o!r under A 21 reamrkt.rottlon ornrr!!n:hark of illypror' 2; Site 11bg ritm or additional well details:
R.Por GerifiroheRlPT or Cased-Lonp Geothermal Wells having the same VOU may use nlc back of this page to provide additional well site details or well
oonslitictian,only I G%1-1 is needed. bidicate TOTAL NUMBER orwclls construction details. You may also attach additional pages if necessary.
drilled: �.ypm-mAI.-m TRI;.0 aQNS
9,lfntal well depth below land surface: Ak) 1M. For AU Warn: Submit this form within 30 days of completion of well
!%rr Ixuhiplc xrllc liv rtli d yrll4a�dij(enrar(rfmr{o1e-g 11f/0'm1d a ri!00) commetion to the following:
III,Static water level below top of casing:,_ � (ft.) Division of Water Resources,Information Processing Unit,
11'nwrrr leer.!is tAire caring toe"•"� 1617 himit Service Center,Rateigh.NC27699-1617
florchofe diameter: ��___(in.) 2.11o.For I"iertion Wells: In addition to sending the form to die address in 24,
12 Well rnnstnteflon method: above,also submit one copy of this form within 30 days of completion of well
-- construction to the following:
(i a imger,rotary.c.•rhle,direct push,etc.!
Division of Water Resource. Underground injection Control Program,
FOR WATER St;PP°I-YWWELLS ONLY: 11536 Mail Service Center,Rate'rgh,NC 27699-1636
13a.Yield(«pin) 4= M1/ method of test! tA 24c,,f[r Vttaler SpptN►'&FaieeHon Wei: in addition to sending the form to
the addresses) above; also submit one copy of this form within 30 days of
13h.Disinfection type:, r� Amount. completion of well constnrction to the county health department of the county
where consttuctad.
I
Farm GW-I North C:amlinn Dcpnnmen[of lin.iranmcrtnl Oaamy-Division of Water Actiourcec Revimd 2 22-2016