GW1-2022-01094_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 p.1
WELL CONSTRUCTION RECORD{GW-1) For)ntemni Use Only:
1 ,ontrattorinlormation:
-' K WATER ZONES —Well C'ontrat2tx Name rttoss Tn DESCRIFrION
Well CnOndor Certification Ntonlwr no iS OUTER CA.�i1Nti for mat6gte0 we OR LiVER a e
I / PROMM DIA 'rli[l9Ct( S MATERIAL
1 `L ft, f4 I in.
Cnmpnny Namc //�� //�� r n^ 1�} 16.INNER CASING OR TU81NG thprma!ctaacddoo
2.1Yell Construction Permit#: v� y D[V 1.1c d- 1 MOM TO 014MEF I TarckNEW NAtEtWL
i.lrr I'll applic-Ne well crntrrrucrien permit,(l.e.UIC.C.nmxy,3mlg Va ta»ec,Cr--) h• k• In.
3.Wrll 115c(check»ell use): Ir. ft. trti
tYa to Supply Well: -iz SCRSBN
—Mom TO DIAMETER SLOTSME TRICKiYFSS MATERUL
Agricultural E)Mtmicip2Puhlic o ft- ft. K
Creothermal(Heating/Cooling Supply) Residential Water Supply(single) g• fL in.
ustrial/Commercial Residential Water Supply(shared) 1&GRa11T
Irri^ration FROM 70 MATERIAL 6MrLACF.ME.VrMP57idD&AMOnNT
iVnn-li'nterSupply�'1'rll: ft. fr.
Monitoring Recovery ft. fr.
Injection Well: -
Aquifu Recharge �GroundwtuerRcmediatinn ft. R
19.SAND/GRAVBLPACK ifa licable
:Aquifer Storage and Recover' USntinity I3saier FROM J To b9ATMIAL trtACrrxBNTMLTIt00
Aquifer Test []SWMW0ter Drainage n' fr•
Iixperimentai Technology fjSubsidence Control tL fr.
Geothermal(Closed Loop) 137'racct 20 DRILLING LOG faftth additional Wheels
ea neaesa
PROM DE5CRTPTiON Crbr, rdaee,taR/rotk t , rate siu,ete,� 1 Cientherm.1(Hrin Cooti`trR Re1a,rn) ^� 01ber(explain under#21 Rem TO arks) ft. IL
.4.Datell'dl(s)Cnmpleted.(I `�C7�Wc1IDt/ a fe. 3 tt. �` �t
Su.Well Location / ft- R. tot t
facilit,'Miner?lame Facility IC61(Ifapplicahle) A. o��D ft
53 �t.C16�1� Cre e-L Tr, krd� 0c, !G�_ft. ft. ati a,srtn
f siml Aeldre s,ary,Ind rip ft. tL J A N 7 202?
21.REMARKS
CmuuY Parcel Cdcntificatinn No.fPily►
(��rl�t(,;EI;III�ia
5b. OCEWNU UN'l 1
Latitude and longitude in degrees/minlittsfsecandsordccimol degrees:
'� ►'iC'?Fi
(ii wo11 field,one latnang is suiricicnt) p r
r3S`a-) 5-
A.1s(are)the well(s)t4p-manent or ©1Temporary tiiitnawrc o Cenifia{WeIlCtmuactor tie
7 1ey tigni»g thin;,r'm,I herrhp erno:that die+w-11(4 wa;(were)crmsu wed in"mrdnace
7.lythlsArepairtoanexistiDgwcll: Dyes or No adrhlSA?iC',1Co2C.0100»r1SANC.ACO2C.•.0200W¢ItC�rrs/nrrtinrrVamloo-dxerdrha+a
011hicarepair.fillmake»nmxrll+ax,arnuirvrigjnrmalio»araicrplaint�e.»mvrtnjnc, i»!!Vnfdttthxlrn)haehra�prots3ndlnlJre well ntvr7rr.
rrgoir tinder i 2!rcmnrkr.rtxr/rdt or nu 1/rr.hark of 11N,r form.
23.Site diagram or additional well deMils:
R.For Geoprobe/i3PT or Closed-Loap Geothermal Wells having the same Vou may use(tic back of this page',to provide additionui well site details or well
mnslntction,only I G%%'-1 is needed. 1'2 i o TOTAL NUMBER orwclis constrvciirm details. You may also attach additional pages if necessary.
drilled — �
a area n 5*,Qft TA1,1NSrRti C."il<ONS
-
9.2'otat well depth below land surface: _.(DJ 14st, F0 All Wells: Submit this fort within 30 days of completion of well
Firinarlliple Wed slilta1)dp11taifdr$crrnr(rtmnple-3C»1100'and 100) constnoilmto the following:
ltl,Static Water level helot,top of taiirrg: (ft.j Division of Water Resources,Information Processing Unit,
1)'av�hrr fur e!ls'+vhrva c7rr/rag.+rae^•" 1617!flan Service Center,Raleigb,NC 27699-1617
11.Bonehotcdiameter. (in.j ZiK For IRjection Weill: In addition to sending the form to the address in 24a
I Z Well construction method- alcove,also submit one copy of this form within 30 days of completion of well
6 C.au a.,re, cin stntetion to the following:
g tap.a7bk,direct pttsb,etc')
Division ofWater Resources,Underground injection Control Program,
FOR WATER SUPPLY WELL,4 OiVLY: 1036 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) illethad of test: 2-tc•Far Wate el r Sany&IRieetion Welts: In addition to sanding the form to
the address(es) above; also submit!one copy of ibis fort within 30 days of
13b.Disinfection type: Amount: eompletion of well construction to the county health department of the county
where constructed.
Form Gl4'-I North CnmlinaDepnrrment,if Iin.imnmrnL�i Quality-I�ivismn of Water Pcmurees Revisotl221-201 b