GW1-2022-01108_Well Construction - GW1_20220107

828.1822-7241 p,1
Fob 1519 05:43p Clearwater Well Drilling
WELL N TION RECO. GW-R. �Pnr lntemn}>1st On y:
1,We1lContrartor Information:
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NC:Well Ca natlnr Certification Number t5. )TER C "+ING for xel�t ORLr1Et a
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Cn npnny wimp. 1JYNER CASING OR 1Ua1NG thortna sUtotl!�
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2.Well Construction Permit 9:t� r} �1 tt IL in.
Llrt all aly+lJrnhle well cnns+nrrainnPC /tr(rs.Ili(:.C.orauy.Stole,Yrrinncc,crr._1
fl. tt. in.
3.Well 1i1c(cheek wd1 use): 7,SC RB N
1�alcrSupply 1Vcli: —4` se. DIAM atAT tc rtttc as 4
hgricultora) MunicipailPuhkic �) tu. f+- '"'
Cicothermnl(I.Ieating(Cooling Supply) aResidential Water Supply(single) tt, �ft. in.
industrial/C•ornmercial f3Residential Water Supple(shared) it ROifi
MA L 81Nt'i,A !tra4 D AMOUNT•
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Irrigation _
1 its f
�Non-WntcrSupplyWell"
Monitoring ®Rccovwy
njecfion ct. •YF� - ft. R•
Aquifer-Recharge pCroundwater Remedialinn 19 3atL _
AquiferStoraJ;c(wd Recovery DSniinity Barrier r+rtatt !>
LAC8M11814TM Nan
Aquifer Test QSmrmwatcr Drainage ft- tt,
Submilenrc Control R'
Experimental Technology � .Y. sary)
Geothermal(Closed imp) h ililillll ht raw An ate.
Gcothennar(Hcatin oolinJ;Return) (hber(oxplain under N71 Rernwks t=ROM - To
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A,bate Well(s)Completed:.J.vf�I well ID#- -------------- -
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Well Loraflan;
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I:tcilih:'{!t !fame ( Facility lDit(ifapplicpbia) R, [L _
Physirnl Address,City,and lip ft' h• 1C7 41-(YlQ
t21.AEMARKR ,roe' ^l+df�Iii�;l•.,:
C.v+nty Pnteol identification No.(PiN) — "—
Sh.Latitude and)on-gitudr in degrm-5/mirurteslseconds or decimnt degrees:
(it well ficTd�ane b0ong ig sufftoicntj , i ? f rtifitnlion:
fi-Ist-A )theweil(s) i'ermonent or DTemporatry nlara.nfrallfied Well convilmor lime
1 ,rtlming dna.lbrnr,J hRrwAy raerflf)i that Air nvlt/..)Wen Ara )crmomeled in accnrdrue
7-b this A repair to An existing well: Oven or No !tA 1.fA vt."'rrC:i)T.C.�Ilgl nr 1SA rYf:M 02f.'.g1nD WeIJ f.:.nsln+rtunr Slandardr and rhae.r
/,r 11Ai.sonpair,Tll(nitkno)wIL4dlrnnarrrCtlnujlf0rmatianaridcrptninthrnnnrran(the cnpprfella+rrrurrthorhRsstprmti�,ftnrf>Lwel(mwte,.
r,wir under+,?l remnrkr scrrmn nr nn tin,hark of lhhfnrm.
23.site dfaRram or additional well dteMtits:
9-tlnr GeoprodetapTor Cinacd-lAnp Geothermal Welia having the came 1'+nn nlay use 111c back of this page.to provide additiomd well Nita detalls t +urt1
Minslnu:tion,only I GWI.1 is needed. fridicate TOTAL NUMBER(if wri on
ls cstntclinn drinilc. You may also attach additional pages ifnocessnrv,
drillui:__...-.__ ___ _T._,.. Illl�'►+ITTaI 11\SfRUGY'tM
9.Tolvil well depth below land surfucG: _ Loa- (R,) yqa, for pN Wells: Submit this form witisin.30 days of completion of well
larm+d!/plcKvlrcli�roli�inrlu jdijJ'¢rcnr(cxmm�la-3n?!IR'aNd lJ(M'J construction to the following:
lot,StAtle Water lltvtl below top of easing: „,. __"-_ -_(ft.) Division of Water Rentairces,Information Processing VAR,
kwalerh el h ahnra caving.ox 1617 Mall Service Center,Raleigh.NC 27,6"-1617
I tioreholediameter: 9 ' .(in.) 21h.For inh±etian Wefts: In addition to sending the form to the adIrmts in 20
/Il to I nimve,also submit one copy of this form within 30 days of eompietlon of well
l2,Well construction methnd: _ r constructioll to the following:
(i c,angc-,rntarp.r,*1C,direct pusin,t'iC
Division ofWater Resources:Underground Injection Control Program,
rOR WATER StTPLlr WELLS ONLY: i636 MAit Service Center,Rntelgh,NC 2109-16.76
1.7a.Yield(fipm)_ I OD ,&thou of test:�� __. ^'I Zie, Fnr WaNx SDnolti&faFactlon WNis: In uoldii:inn to sanding the Ibrm m
the address(es) above; also submit. one copy of thi+: form within 30 days of
t3h.Okinfection type: Amount: completion of wdl crrnstniction to the county itoalth department of the county
where constructed.
loom CWI North Cnnnlinn Divts,onOf Water Ro%nurcaa Raviso42-22 2016