GW1-2022-01107_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 p'1
WELL CONSTRUCTION RECORD(GW-I) For internal Use Only:
/
1,Well Contractor Information:
-,� k.3-7�1t<.r ��� T 14,WATE ZONES - -
Well Contraaddut Name Egos[ Tn Dl seartrrrorl
R.
G. R.
VC VJe11 CnntratYnr Certification Nirtnl+c I&011TBR CASING for malOtased welts OR LINER ifn limlite
PROM TO DIANMER 'IL[CKN MA1191tAt.
I it. OR ft. in. U
Cmtilviny Narnc 1 _ ,,/-� -16."Fit CASING Oft TURINC theraud ermN-loo
2.Well Construction Permit it: L-d 7T U111�--� irRo+s To DIAMETER I lxtcutvcss nuL
i.l.rr all op/rNrnbla mcl/cnnuredimi p.:rntile(l.c.tl/C;C.merNy,Slats,Irarlam•a,clr.)
Et. ft, In.
3.1*01 lrle(cheek well use): fh ft. In•
Wo ter Supply well: 171 SCREEN
FROM m DlAtrrL'M LSE00TSIM Tr1ICKNrM MAT6MAL
Agricultural �Municipal/Public () EL ft. In
Geaherm8101cating/Cooling Supply) Roidential Water Supply(single) tt. tt in.
rndusirial/Commercial Residential Water Supply(shared) 18 CRO11T
lrri^ati0n F O TO MATERIAL 6MrLAC EVT n7TiOn&AAIOUNT
tYno-Water Supply Well: rr. R.
[Aquiier
itoring Recovery
on ell: - -
ff. R.
Recharge ©Groundwater Remedialiao 19 SANIUGkAVEL PAC K io liable
ferStgrilgeandRecovery []Salinity Barrier PROM TO MAT L rerTcst ©StnrmwaterDrainagerimental Tcehaology [:pSuttsidence Control R.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG IsMsch Midi id ifneeetsa
C>eothcnnal(Hcatin colingRctum) Other(explain under021 Remarks) f oxr To es mtor.turauheetrr &Mtnskecct
tt. fr- L
A,[late Well(s)Completed: I�_�`-?-1 Well 1Dfl R '1�tt• (` J_
Sn.Well J.ntxtNnn:
�l lDPW*( R. �.
Ficilih:rll rrer)lame Fa�Ally1Dt!(ifaPplic�blrj 0 R"
laical Aedres, ,ity,and zip ft' R J AN 7 ZOE
ttl Ilil/� 21.REMARKS
Conoty E'ateel Idernifieation No.1PIN)
i��� SAC
Sh.Latitude and lonkltude in degrees/minutes/seconds or decimal degrees:
(if%vell fr l�ne latgnn�is suiricicnr} i 1 1I 22.Certification:
W :-Mai L z§� I
6.ls(arc)the welt(s)�P2rmanent or ©ITempnrary Signnlure of ceriifral Well tractor Date r
�� Iry.opning Onx Psrm,I Iterrhv acrrlJl:Thal the WI(q mar(rare)ernul"esul in acmrdance
No wid,15A.tic:AC a2t".g1Ul1 Or 1SA NCAC RX.'.02IO N e.11 nnsrn:rnen Vamlarrrc onid lhm n
7.is this a repair to an existiag well: oVes or
1,r1Lir i.—repair.fill mrrkm m w.11.:aasirrrcnmr irtformalicin and rrprain/he witire griha eaP.h r 1&V reemrllmc bPP1t nMtRrit7f to I/a:w.rf(nklui.
r:racrlr rmrlev G 21 rcmnrkr scennrr ar nn I/re Mrk of ll+is jattn.
11 Site diagram or additional well details:
A-For CeoprohellfPT or CJnsed-Larip Geothermal Wells having the same Vou may use the tack of this page to provide additional well site details or well
c t?nslniction,only I GtW.1 is needed. Indicate TOTAL NUMBER or+slls cutistructina details. You may also attach additional pages ifnocessary,
drilled!_
_.P _ .»_ 1 1.t'�,.2 R.) ��.�LJll1.1KITS I�LICTTONS
9.7rotat well de t1t below land surface: - _( 24% For Alj-Wells: Submit this foml within 30 days of completion of well
l�ar NUMPIr6•rds/A#all d grfAa ifrlijJcrenl(riamol4 tn�an•anr��nron7
O construction to the follolring:
10•Static water tevcl below top of casing: (ft,) Division of Water Resources,Information Processing lJnit,
I I.ftoreho irrrlvrva racln�.mr "( 1617 Mil Service Center,Weigh,NC274"-1617
I1.Iiorcholedinmeter: f� 24h,For(affection Wells: In addition to sending the form to die address in 24a
1Z Well construction method: above,also submit one copy of this form within 30 dare of completion of wen
(i C.rulgar,mrup,C,*]C,dircvt pusat,Ac,) construction to the following:
Division of Water Resources,Underground injection Contra)Program.
FXM WATER SUPPLY WELLS ONLY: 1636 Mail Service Cenmr,Raleigh,NC 2700-1636
130.Yield(gpm) 7_ Method of test: 24c, [fir Water Supply&(aiection Wells In addition!o sLaiding the form to
the nddress(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: _ Amount: completion of well construction to the county health department of the county
Where COPS[meted.
Frimi OW I North Clnmlinn DePnrtment of lin%imnmcetnl prral0y•Division of Water Resaircec Revised 2 22-2016