GW1-2022-01105_Well Construction - GW1_20220107

Feb 151905:43p Clearwater Well Drilling 828-622-7241 p•1
WELL CQN-4S R•1ii&TION 12ECORD fOW-1l For internal Use Only.
1,WelIC,nntraetorInformation:
A\\In 14,WATER ZONES —Well Contractor Name PROM n DES R1P r10N
fA
C Wel I C///Itnntmelor Certification_Ntrrttlrer, p IS OtTr.F CASING for matfl ctutd weih Ills Lf?1Fdt if a 1 t
1t I ro pRDf�1 M .A, T 'Mot S MA tAL
y�J t4 ft. 11 in.
Co;npnnv Name _
16.INNER CASING OR TUBING thormat cteatd-loo
2.Writ Construction Permit#: -MROM I to I DLU"ETER I T9t MAE-- L
410 all applicable well ceartmetion parmirs(1.c,tJlr:,Courdy,Stale,Varlamv,ch._) ft, i ft. I in.
477
3.lVeil Itsc(check well use): n• h in.
Water Sapply Well:
�17.$CRBSN
OM r0 OIANSWR BMT- Z6 TH1CKNEss MATERIAL
Agriculhtral �MlmicipaUPubiic
Geothermal(lieating/Cooling Supply) Residential Water Supply(single) n, tL in.
[ndusiriat/Commercial Residential Water Supply(shared) I&4GROU I
Irrigation FROM TO MATX 1AL 8MPLACEME-Vr141 TMOD& OtlNT
Non Water Supply Well:
t\4o,itoring Recovery
injection Well:
fl. D.
Aquifer'Recharge Q(troundwater Rcmediation
AquifLr Storage And Recover), [)Salinity Barrier FROM NnlGkro L PACK M1r e kaALle tleatirtwcentBnT Mcr►ton
AguiterTctt DStnnnwaterDrainage
Experimental Technology [)Subsidence:Control
Geothermal(Closed Loop) DTraccr 20.10)RI1.LING Lox faMsch _alalttets Rpr=M
RGeoMennal(Ncat➢n ootint;Rentm) Otber(expinin under fill Rcmarks) FROM ro DE5CRt11 x tobr.InrGrtan rott/rockt CAR seu.Ott,
l
h. IL r
4.02teM+e11(s)Cnmpletedj c)-4— t Welt iDr/ t O 1
5 a.Weil I.neatinn L h•
D It.
F-Xilihsah,en,er)1Atne ft. ft.
Facility iDit(tfa7�plicablc) r-•,,•� �-
P sir�l Address,City,and 7,ip
I ft. IL
LK
xl. MARKS
County Parcel identification No.(PIN) A
Sh.Latitude and longitude in degreeslmimttes/secondsordecimal degrees:
(iiI volllt field,one latflanglat4ang is�s`o,friicicnt) I b —( ' ficntinn
t t 3! 4p�i N-1
fi.Is(are)the well(s) ermanent or C)Tempnrary M our i'Cenified W I Cem r PAC CJ`
.�,( Iry slEming r/rts Hrrm,I berrby crtrify that the ttvll(s)war(wen)cretsynWed in acowdo ce
7.iy this A repair to an existing wen: E)Xcs or No r•ith iSA.GC'AC-'0?.C.U/0U or 15A NCAC U11.V0200 WeN Gi ns(n7(r1ON Standards mud Mae a
/,+rJ+ie i•s a relmir..Q11 maknann will eaM-Uractltar oformatiatm-r arplairt the nnnrre a(thc copy afdlif record A=Alen pmvldedIn the weft natter.
r::,air under t,11 remarks secoon ar on the bark of Ihia.fatal.
23_Site diagram or additional tt:elldtaeils:
R.For Geoprohe/DPT or Closed-Lang Geothermal Wells having the same 1'ow may use the tack of this Page 10 provide additional well silo details cm well
WnSintctimn,only 1 C A1.1 is needed. 3'ruiiratc TOTAL NLIMBBR ort�'clls construction details. You May also attach additional pages ifnecessefy.
drilled:
IMIRUCaONTS
1.Total writ depth below land surface;___ 114
yla• COY!All ftls: Submit this form within 30 days of completion of well
I%armnitrplevrllcfivalidrprAr�A+�errne(rmmale-7(�lI!/'01and�r�10n� construction to the following;
16.State water tevc)below top of casing: v (ft.) Division of Wurer Resourees,Information Proeessiog Unit,
11'w014rlure!h•a)wuarining•axe •' 1 1b17hiall Service Center,Rattigh.NC2'74"4617
Ii_Borehole diameter: I V (irt1j /� �� ?,M.For iwiertion Wells: In addition to sending the form to the address in 24a
Vt�12 Well constneetlon method• 1 ( �'( stove,also submit one copy of this form tvilhin 30 days of completion of well
(i c.nu �,ra, to construction to the following:
[,. rtq•.cable,dirml tsh,c(c.)
Division of Water Resources,Underground Injection Contra)Program,
MR WATER SUPPLY WWELI..4 ONLY: 11e36 Mail Service Center,Raleigh,NC 27699-1636
134.Yield(l;pm) 5 Method of test:_Rite 24c, For Nralcr Sundv&Infection Wells: in addition too sanding the ro m in
the address(es) above, also submitonc copy of this form within 30 days of
13b.Disinfection type: Amount: completion of%Pall construction tD the county health department of the county
where constructed.
l+omt G�1't Montt Carolina Depanmont of Grnirtinmental Quality•Division of Water Rayourm Revised 222 2616