GW1-2022-01071_Well Construction - GW1_20220107

828-622-7241 P,1
Foh 151905:43p ClearwaterWollDr•illing ��........•.••
WFLL C41q§P-- 'rM I2F.CORI�fGW-l.l Par intemni Use On y:
ll Cnntrartor Information: ---
rttoK •rn pE9CturrtoN
%Vclt(:o1inclot Name
NC:Well Cninmaor Certiliention Number S.011TEKC r+1NG for wel4 0 IRK Id�1ER ifa
TO D1AER
v ` ► ft. b. in,
Cm,pnny Name � �1. O 6.INNER C 11VC tHrt'fIIB{NG therms tltead-tat
l ` , TO D TAIGIC/V S MA tRntAt
2.Weil Comttructinn Permit 1 O� 1 ft B- in.
i.lrl all applirrtble well rrmoni.Minn pounder(l e.OR.Cnnwly.SMIc,Valance,cut) ,� •
3.NVOI ilgr-(chctk well nsc): '17,sClle N
Water Supply Well: '"�a m _ VIA
+srAT• � 7HtC, rrss Ar tAL
Agricultural �MtmicipallPuhlir 0 rt, ti. in.
Geothermal(i.•Ieating(Cooling Supply) E)Residentinl Witter Supply(single) tt, tr m•
industrial/C,ommaroialResidential WaterSupply(shared) "18 GROUP
irri^allOn NRDNI TO MAT 81/FL &M�GP !rr 1 D A OUN'r
ft. t4
Non-Water Supply Well:
Monitoring [311ecovery
injection el: ft, it.
AquiterReviiarge E3frronridwaterRemedialinn -tySpivT)/GkAVSLPACK Ka table
:Aquif,'rStorflgc and Recovery 0Snlinity Barrier L LACEMB[ITM�7li
Aquit2T Tcst []Stnrmwoter Drainage
L•'xperlmental Taclron101ty
Subsidence Control In. n'
Geothermal(Closed Loop) �Tcaccr R.i1R113,1 ,Lt)G attach of alydttata l am
FROM Ioat rt rowrror�.nt7,t, r�luroen____,!r�. r •,e' t
Clcothcnnal iHeatinPJCealinR Reatml }()<her(oxPlain under f121 Re Arks) re. fe eD � �wjG�
A,Date R'ell(s)Cnmpieted:1 Z-U 2l well 1D1/_ t. it. fQ;/)
sir.Well Lo"llon:
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w
y
t drama Faeility[oil(if:ytpliC:khlr.) _ n' R _.
P ival Aedrem,City,and f°fp
y 11'ftF.M-ARK£+
Caunty- t'Atepl rdentificntion No.f PINm
5b.Latitude And longitude in degre m/mimites/seconds or dedronl drgrecs: t
(it mall Fieeld,anncc latilang iin nuffielcnt) Dr 2. •.er cation: D A SECTION'
`Cr F3Iy �V `Cy ` `-W
A.1s(arc)the well(s)MPermnnent or OTemporary i urcafCartifiadWellCntttrttaor Dree
l v.rl}Wing rbi.s'pwhr,!hewhv crrrlhr that fir na11(a)Kxr firer')comomrind lot VeLmdn.•rcr
7.is this a repair to an em feting well- Ves or o e irh 1.SA,Vf'rrC:VC.000 Or 15,4 rV(,Ifr 02C.N200 W"ll Cancfn+ri n'Slandarda and Arm a
lY'rbiri.varepair..Rll(nit known ivelleanornclionh1formalion kwithiplainlhcrtnIon!gfd,c tnpynflhicrrrnrrlhaedregpmtd&ilrntlu twflJmvt7rr.
n!,•mir Wider a 21 remarks-sccnort rornoMe hark afrhh.fnmt 23.Site diagram or additional Well delpils:
R.I/er Gomproher9lPTor Closed-I,nop Geothermal Wells having the same )'ou ma.'l use Ilto back of this page to provide additional well site details or%veil
emstnmtinn.only I GW-j is needed. Indicate TOTAL NUMBER orwrils constnrtion drt»ids. Yet may also attach additional pages ifnocessory.
:�"1"t` r5•
�►•Fatal well depth below land surface: r_�fR•1 2-la. 1>or n�Weds: Submit this form within 36 clays of completion of%veil
FnrnrnlllplCmwhliunlidpthcY'dijfemnf constniction to the follOWUL2:
10•Stacie water i"Cl below top of easing; (ft.) Division ofWarer Resources,Information Processing Vail,
0•01rr lure!h alanat coring evt`•'• 1617 A1all Service Center,Raleigh,NC 276"-ifi17
i I_Roreholediameter: ,(in.) 24h.For Iniectylln We ts: In addition to sending the form to die addre9 in 24a
ultove,also submit one copy of tills form within 30 days of compidxlon of well
12„Well cnnstnaetlnn method:
0 c,mrge,mhug.cable,dlrout pwilt,;xc.l cttnstructintt to the fotlnwing
Division ofWater Rcaourcesi Underground Injection Control Program,
GOR WATER SI.PPI li WELLS ONLY! 1636 Mail Serviet Canter,Raleigh,NC 2709-1636
1311.Yield Igpm) Vi ethad of test: i 2.1c. i/as-Water Sanlaih•&Infection Wdis: In addition to sanding the ibmt to
the address(cs) above,
also submit one copy of this form within 3n days of
13h•Iltsinfection type: _ Amount: comptetion of%veil construction to the county health department of the county
where constmated.
FaMI C W.t Noah Carolinnlhpnnment ni t:u irnnmrrml Qnanty-nivismnof water Ro%nurccq Revised2-22 201 b