GW1-2022-01124_Well Construction - GW1_20220107

Feb 151905:43p ClealwaterWellDrilling 828-622-7241 P•1
WELL CONSTRUCTION RECORD{GW-11 For InicJnaT Use Only:
1.W�IcT S.ontraetnr lnformatian:
14,WATU ZONES Well(b11n Mae Nalne - IRON TO DESCRIPTION
ft.
VC Well CnntragorCrxtificatianNumber IS*OUTF.RCASING rormn]fi-pnedwells ORL(NFRt lfa e
NstOM I ["Ammit I 'rll[CKN889 MA'1'rdt1A/L
Company
omV Nanna 1 16.INNER CASING QR TIMING thormat dosed-lo0
2,Well Construction Permit#:c j," OM 110 1 DIAMETER THICKNESS "ATERfAL
00 all applicable well c»nrm�diar p•.rmitr(i.e.111l;Cnnrny,Stale,Yarlanec,cm..)
3.Well Ric(check well use): n. tr. io-
IVatcrSupply �17.SCRB;EN
Agricu FROM TO DIAMETM I.OTSse THICKNt[ss MATERIAL
ltural
�MlmicipalJPuhlic () tt, ti. in.
Geothermal(I•leating/Conong Supply) &Renqidential Water Supply(single) iL in.
[ndustrial/Commercial iffilesidential Water Supply(shared) Ig GROUP
in[i ntion FReNM TO MATXRKAL EMPIACEMCAT316TreODhA FOUNT
Winn-Water Supply Well: rt. is L4�
M er.H;onitoriWell:ng Recovery ft. ft-
- -
Aquifer Recharge G ft. It.
Remcdialion I9.S,IMI/CItAVEL PACK [a livable
AquifiYStprARc And Rcc nvctq Salinity Barrier FROM T41 MATERIAL ffimRLACEMBNTMCTIi00
AquirerTcst QStnnTtwaterDrainago ft- ft.
:)ExperimentalTechnology [jSuhtidenu Control n. ft.
Geothermal(Closed Loop) [Tread 20.nfT3(.LiNG LOG attach additional abarls if neaesss
FROM TO DESCRIPTION eabr ,jakhmkt strata !Mete.)
Getrthoxrnal(lteatin oolintQ Rcnrm) Other(explain under 821 Remarks) tt. fa
4.date Well(s)Completed: 1 —�,�Wcll ID# it. ft.
54.Well Lnentton.
fl:tcilih:7lxaterltamc Faialit�ylDpr!-(iiffarnplicWr) h• ft
{' 1 6 b `CC V Tr. Ct�.j'l.V(Jn R. h.
Physiroi Address,City,and Zip ft. R N
a31.REMARICS :tser'r hli\L3 1 :I
County UParcel identification No.ITiN) -
511.Latitude nod longitude in degrees/minates/seconds or decimal degrees:
(if,v�lt field,one lattiong is suirrcictn' p „2.Certificai
h.Is(arc)the well(s) Permanent or ©1Temporary Sign nor Certi5cd Well Contmetor Doge
v.up"inq rhtr.irrm,I herrhv arrrlfj,shot file nrlf(..j dins(ware)mmomrred is aeaordanee
7.is This a repair to An existing well: Oyes or ONo wi0r I.SA A7.*.AC 02C.0100 or 15A NCAC 02C'.0200 W,41 C ws/ntenan 3tandardr ant ihnr a
4"Ildr is:�rcpatr,f/l mrrknnnn ncJ1 eoaarvcn'n»infnramlian mu1 arplain the rxrmn•grlha toplc ntlhi.t..-cord haeAran providmto I&w,111 miser.
wpoir under RN remarks.socomt or an lln:nark nfthta jorin.
23.Site diaRrtrm or Additional will detnNs:
R.For GeaprobeRlPT or Closed-Loop Geothermal Wells having the slime You may use the back of this page to provide additional well site delnils or well
exlnstructinn,only I GW-1 is needed. 1)uticate TQTAt.NUMBER nfwctls construction details. You may also attach additional pages if noeessaiy.
driAui:
�� �;1L RM!'J�AI.iA;sST�tIG'i'[ONS
9.7 oral well depth Trclmv land surface: ( •) 2 rnr Au w form within Submit this fo within 30 days of completion of u 11
Pont»lliplcxrlttlittnlid.oflarfd;,d-cry»I hapnpin-.rCnilrin•and 2@1001 4a.amsin[cfionto the following:
I0.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwale"lura.isalwraeasfng.we'-/ - (I 1617 Mlaii Service Center,Refelgh.NC 274"_1 617
11.Borehole diameter: lSf 1 —(�ln,) ?rah.For IwMction Wel)r. LI addition to sending the form to rite tuldreny in 24a
I Welt construction method. / V almve,also submit one copy of this form within 30 days of complexion of well
(i c.nu•c,rn4
{n1sh amst[netion to the following:
t,. Zrm•,atble,direct ,etc,)
Division of Water Resources.Underground injection Contra)Program,
FOR WATER SUPPLY VVELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) LD iNethnd of ttsl: c 24c, hod Water Sancti &(nFeeHon Welts in uddi[icrn to ending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of Weil construction to the county health department of the county
where constructed.
loam OW-I North CAmlinu r:cpnnrnent of tinoronmentnl gtrafity-f)ivistno newater Rasaurcas Revived 2 22-2016