GW1-2022-01115_Well Construction - GW1_20220107

Feb 151905:43p ClearwaterWel)Drilling 828-622-7241 P•1
WE&L CONSTRI;7CTION RECORD(GW-1) For Internal Use Only:
1.W llContraetor Information:
0'r L A I QJ t 14 WATER ZONES —
"'• 'PROM TC) DESCR1rr10N
Well Cantratlot Name
tL
32 Q' - fi.
(.p t'/n�- ;—it. t+.
C���Well Contractor Certification NMnnher 1 OtTrER CASING formal ed welb OR LrNER(litaidicebtel,
TO DIAMETER -ralcxNEss, MATERIAL
Company Name 16.LKNER CASING OR TUB ING tfiormatcloaeddtw
2.Well Construction Permit#: FROM TA DUMEK Tat MATERIAL
iAsr all applimhle wet!canrinrellan parmits(i.e.INC.Couaiy,Stair,t44riMW(:,cr:) ff. Ift-
3.
lYctt Ilse(checkwell use): n.
TYi ter supply Well: -17.SCREEN
FROM !O DIAMETFxt SLOT91l.E TRICKN6S6 MATERIAL
Agriculhtral MtmicipaUPublic () tr. tl. i>w
Geothermal(t'Ieating/Cooling Supply) Residential WaterSuppl-v(single) B• it, in.
[ndusirial/Commercial [3Residential Water Supply(shared) CR i-
I&
[rriDation KROM 7Q MATERAL EMPWCEME`ITMFTRODEAMOUNT
Nnn-1►'nitr Supply Well:
R4onitoring Recovery
njeetion Weil: -
Aquifer Reclfatgc E3Croundwatcr Rcmcdistiun ff. it
18,SANO/CittlYfiL PACK [a !i ble
:Aquifer Storage and Recovery' E)Snlinity barrier PROM TO MA tAL I PJN}rACEMBNTMETItOn
Aquifer Tctt ©swrmwater Drainage n_ ff.
Experimental Technology 13Subsidence Control R
Geothermal(Closed Loop) ©Tracer 20.DRILL NG LOG age addidonalshoeft fneeessa
DESCRtrrtON minr,harAaw.wWrec4 f . rain sfu,ctal
G tineothermal(Nea oolin Return) Other(explain under#21 Remari: FROM To
S) tt. fL 6/
4.Date Wells)Completed:)�')_�I Well ID# ft. `''Lys/
ob fl. &, ".'
(.Q Sa.Well l,.n�cr,tlnn: y I/
l srilih:'(lHmcr)tamc Facility[Diu(ifanplicAlc) n• (L
Ph sicil dress,City,and Zip
V21.REMARKIS •
County Parcol identification No.QfW)
:Sh.Latitude and longitadr in degrees/minutes/seeondsordccimal degrees:
/0iw-11
�rieldd one IInOong ir.sufficient) (� ?Z,( r fiCndoM
6.ls(are)the well(gMil"Imnnent or 13Temporary Sfgn urcofCeniried Well Contmetor Date
Iiv a tmigg rNlc_;rem,I hrrrhv crrllfj:that!hr nr/l(a)was(wee)exmormard in accmrdancr
i.is this a repair to An existing well: OYes or No vdth i.SA.vt'A('o2C.#/t10 or MA NCAC 02C.0100 Well("morricnan Standards and Am a
'&h.is n renair..01 rnrrkmim urll conwmcur"i infonnallon a. rj1%Wn the:noire grrhu tnpfr nfl/tfr rtrrord here hero pmttide rf ra lJa wall rnHtri,
r:;xrir rude r:N remnrkr scc0mr nrna rlrr.lurk nflbi form. 23.Site diagram or additional well details:
8.Par Geoprohe/DPT or Closed-Lnnp Geothermal Wells having fhe same 1'rfu play use the back of this Vagt to provide additional well site details or we!J
afmtnictinn,only I Gtt'-i is needed. indicate TOTAL NUMBER orx%rlts construction details. You may also attach additional pages if necessary.
QRMrFTAI.IA4TRticu iVS
9.!moat well depth below land surfaces —(lL) 2,1% for All Wills, Submit this form within 30 days of completion of well
I'nr MUlriple"e4f lAs acid pdu ifdii different(rcan{ok-.10100'on/d�<<it 100) conatniction to the following:
In.Static water level below top of easing: `i`y✓ (ft.) Division of Water Resources,Information Processing Unit,
Jf x•aler lwr.r is 1WVrv6 casing,1r e " 16117 h1ail Service Center,Raleigh.NC 2'/694-1617
I L 13oreholedinmeter: (Y (l� 24b.Ror Iaiertion Wells In audition to rending the form to die oddraa in 24a
17.Well construction method: /--I)--� alcove,also submit one copy of this form within 30 days of compleVon of well
0 c.:urgc-,MWY-C,*Ic,dirC%t I MMsh,e(c,) construction to the following:
Division of Water Resources,Underground injection Control Program,
FOR WATER SCPPf j/W7ELLS ONLY: i636 Mail Service Canter,Raleigh,NC 27699-1636
13a.Yield(gpm) ` C� 'Method of tell: 2.1c, l;gr WHor S.ppnlf•&Folection Wells: in addition to stmding the form to
the addrecs(cs) above; also submit one copy of this form within 30 days of
13h.Disinfection type: .Amount: c.,mptetion of well construction to the county health department of the county
whcre constructed.
Font C'W I North Cnmlinn Depnnment of Envlronmcntnt Qnaflty-Division of Water Restnircec Revised 2 22-2016
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