GW1-2022-01087_Well Construction - GW1_20220107

Feb 1519 05:43p .Clearwater Well Drilling 828-622-7241 P.
WELL CO),1§R"TION RECOR&(GW-a) �For intcmnl Use Only.
1.Well CnntraetorInformation: ,
J©sh - w)w ._i�w ai>'NEs ----
ppON TQ apicit rrrON
Wolf C:ontraam Natna
4�3`1 - �. lt. n.
vC:Wdi Cnntragor Catifiaation Number �\ iS.OUTER CASING for tr ido-cased wells OR U NIOL if n e
/j f ' PTAME7tGR 'rll[t]C}IP.BS MA'1'EItUL
('h �•J tr, tt. in.
CaatpenyNnmc �(�� 1 y L6.LNNERCA8ING(WTURING thtaunatelatedlao
Z.1Yc11 Constrnctinn Permit#: r `r -1—— �1�`� �� K To ouMcrna rntcvess MATEntAL
ft. Lt. In.
i.i.et all npplicnbla well cnnrtrtrrtlnn lwrmi/.r(l.a.111C;.C"mr/Ny,Sra1G Yrr•tance,crc:l
3.1Vt111tic(ehcett+vrl]tree}r
n. ft. in.
Water mpply�1+ell: �L7.SCRBRN
FROM TO nIAMlirl;it SLOT9d.R THtCKNg96 TRRGI.
Agricultural E)Mltnicipapuhiic (? tt, fl. in.
Creahermal(1:leating/Cooling Supply) Residential Water Supply{single) tt. ft in.
(ndustrial/Commercial C)Residential Water Supply(shared) 1a OUT
rInretion
iion
O
MArLRGL SMPAC6Mr.VrNWMODdAMO-
UNT
nterSuppivW il:
oring Recovery
Well:
erRebargc E3GroundwatcrRen+edialinn f9,S.1N11lGkAW$LPAC) ifs hle
Aquifer Storage and Recovery E)SaffnityBarrier pR011t 1yD MWTJORIAL )r?ItrLACFMaIVTMCittOn
AquitcrTcst []StonnwatcrDrainage r' ry• _
i Experimental Technology [1Subsidence Control ft n•
Geothermal(Closed Loop) 13Traccr "2(F.DRIi.1.ING LOC man additional faneesa
, V ETO OR tutor. mWroak t tall sire tttJ
Geothennni(HcatinWcooling Return) Otber(ex lain undcr N21 Remaics) ft. ft
4,Date Well(s)completed; Well ID31__ ft,
_ rt. h. d1(� �
f+ue_Wrtl i \
ncatlna: _
VWfr. ft.
]:teilit�:t(!av%cr Tlamv `�'l .1. iDi!(ifapplicnblr.) �' R
PI ts'ic/n�I{A�ddrc^cs,City,an4 7.ip n, R-
1 4l1 is y�{n l�nl- 21.REMARK$
Clon(y parcel Identification No.(PiN) [ C
.. I,tf�ll�!Sit,l IUltr
5h.Latitude and longitude in degrees/minuteslseconds or decimal degrees;
(i�t field,Done tetq`ng is Rufiicicnt) o p ;!2.Certi 'on:
fi•Is(arc)the wells) Permanent ar DTemptrrary Sipn c of Certified Well Cantntwor fate
let.v in/j turn•.;trm,I Acerb%a+atYtf):rhat rhr iw.!)(.v)NWr hrarr)txrtesrnrNcd Nt acthrdancr
7.1.4 111is a repair to an existing Wen: Oves or W o rdih LIA SC'AC VC.OJ01)or'rSA N(,AC.07C.0204 Well Constenr ur)r 3ramdards and that a
J,t'rbfr ism rvpoir.f)l nurbenam w11-reoestrnclitnt iryfarmatirn.01d rsplain the tutnnr nfthc tal?v t!fdlr.'e rr,vrrdNoehAm pro tiled to t9ujwell owwr.
rc malr nailer,!.'(romrkv sccwB or rot Ifre hark.afllits.(ornr.
7.3.Site diaRraro or atlditforrel well de:Mils:
R.for Geoprohr/DPT or Closed-iAnp Geothermal Wells having the same 11011 may use the back,of this page to provide additional well site derails or well
ex?n slmctinn,only I GV✓•t is needed. rrtdic `�TOTAI.NUMBER or\vrils tonstruchnn details. You may also attach additional pages if necessary.
SiF ).+,Ihe�'Rttt�„rljS�l►'Is
F- 7fotai•we0 deptlt jj'&Pf land surface: 244 1F'or•fit,(( ells: Stlhlllit this form within 30 days of completion of well
l rr nrvhrph wrll.c litt a!i d.:p/ltr ifdi,�eront(esamp/s-9n100,Ond c�tlr.d00j
construction to the follo►rin&
IA.Stone water level below top of taring-,r (It.) Division of Water Resources,Information Processing Unit,
J/e'nh r fern!is rrhrroe crrr/np,uac 1617 Allah Service Center,Raleigh.NC 27499-f S17
11.1)orcholediameMr: (in.) 2th.For Infection)Wls: In addition to sending the form to rite nddreats in 248
12.WCO constructlon method: above,also submit one copy of this form within 30 days of COMPIC60R of Well
(i c.mtoc:,rotary.ailde,direct 1at5h,etc.) construction to the following_
Rbl1 WATER St:PPf.Y WF.I.LS ONLY: Lj
Division ofWater Resources.Unde'rgroulld Injection Own)Program,1Gad Mail Service Center,Raleigh.NC 27699-1636
13a,Vittd(gpm) Method of test: 24C. Igor Wstcr-%ngV&fglactlon Welts: in addition 1d sending the rmm to
the arldress(es) above, also submitone copy of ibis formwithin 30 days of13A.Utsinfectton type: Amount: completion of%veil construction to the county health depatiment of the county
where constructed,
Faun Gw-I Writ Cnmlinn Olean ty•Divistan of Water ttasourat c ReviaeA 2 22 1Al b