GW1-2021-02686_Well Construction - GW1_20210823

828.622-7241 P.1
Feb 1519 05;43p Clearwater Well Drilling
WELL!CON§nP&T1QN RECORD fG'W-111 Fnr In(crnni Use 711Y-
1,, cllC,antraelorinformation: � i -
tUNE6
t+mou In, nvscwrrcorM
Well r'rnlrnaor Name to fi• �_
NC Well Cnntmaw Ce tifiention Number t)l1TER CARING or Mmol wells OR 1Li�i>�t a e
nROM TOoietrt lt.n. rtllMaciass MAicaut
Cr mp�my Namr. t
._14.tNN6R CA9INC(M 77r81NG tharMaai etosretbtoo MAtEptAt
yi TO outa� 'rntclav>vss
2.Well Constrnetian Permit K: ��S-Le `� tr fn.
i.i.et rrli orlrlicable mall mminretfan psrmnr(l a.VIC.Cnnrdy,Stale,lrarlmrcm,cl-)
n• R. i"^
S.IVAI Use(check well use): 17.SC
WA terSapplyWell: ono ro tsuMsrar sr or nrtctarlrse MATERIAL
Agricultural D'MmticipoUPubRe R• ft.
Geotncnnal(licating/Cooling Supply) Residential Water Supply(Single) R to
IndustflallCnmmerciai �Residential Water Supply(shared) .
M TO MA•t�RrAL 6MPLAC g,.rf}1B7rtOD8AMOUNT
rtrl'-mien "i o .�
;Von 17'nr er3npptyVlcl l:
Monitoring Recovery f&
injection Well: fl. R•
Aquifer Recharge QCroundwaterRcmediation ` I9 sA �LPACK
.Aquifer Storge and Recovery aSanity Border To NATRLAL flltrlACFs1EKhWn'Olt
AquilerTest Q.SmrmwaterDrainage r_ n'
Urperimentat Technology [3Subsidenee Control t► R•
Geothermal(Closed Loop) [37raccr 20.pRlLt rNG LtJC attar h ad coefraelc r In mu etc,
Lf? TO CIA'GeotGamai Hcatin oolirM);Return! Other ex lain under ii21 Remarks) tr.
A.Date U'ell(s)Completed: P _._r_f)°Well IDt/ ) fr. 7 2A It. 1 L
Sa.WeltLocaftno:
�y �
fL
I scility'(1unM)damc FFracr7ily ll)il(if applicphlc) n' '
rhysiecnli,Address,e;My,and zip
\�4.�.9 lr" 21.REMARKS r;rr.{s�„
Canluy t Pareel rdernifleation No.QM4
Sh.Latitude and lonprtude in degreedealnates/secondsordeeimni degrees:
6"well rr-ld,one InMons insufficient) �}® ertil lion. Z
6.1s(are)the Wdl(s) Permanent or Temporary "ip ll orGeniriaiWellCwrvamor Drue
13v.rtlming tills,;»m.I herrhvcWtify that the NX(.r)was(wmL)CWWn dart m oe-rd-Inee
7.1.this a repair to an ctistiag wcD: Oyes or No sdgt iSA 4f AC oT.l .I11Dq or 1SA NC.AC.a2C'.021t0 A'ef!Cuntmarnn Vandn+cic mod thm
dr
1,11hirixarepnir.fillmrthtr)nm /lieanivregrAv enplrnfillotr.iyedAm been Provi"JD the WHIa%wer.
a., it under 01 rem rkT.UVI BM ar Mr the hart of fills famt.
23_Site diagram or additional acll details:
R.For Geoprahe(IIPT or Closed-1 Amp Geothermal Wells having the same 11au may use tl►c back of this page to provide additionat well silo details ar well
Mxnstructian,anh I G%'I is needed. indicate TOTAL NUMBER of-.ails construction details. You may also attach additional pages if necessary.
drilled: _ -- 5V3M=Ai,IN _ tSi iR I ITONS
9,711tit well depth below land surface: �0� _(H! M.ftr AJ_Welis: Submit this fomt within 30 days of completion of well
1%nrmnl(iplcNleHalistnlidtpduifdaaerrnt(estanpla-3�1N111andc�a110tt9 congMtrAi0t1101bCjb110147ng:
In.Static Water level below top of csaing: (ft) Divirdon of Water RestturecS,Inthrmadon Processing Utrit,
!j emdrrAre!is cAird coring,I="• Q 1617 Man Service Center,Raleigh,11C274"-1617
ti_Borehole diameter- 1.1E (in.) 2Ah.Fnr fatertioa Weller In addition to Sending the form to the address in 24a
lZ We1r construction method: above,also submit one copy of this form within 30 days of completion of well
construction to the foilowing:
(i c.0118-,-Mary,wbla,direct push.140
Division ofWater Reaourm%Underground injection Control Program,
FOR WATER SUPPLY WF.LL.4 ONLY: �] 1636 Mail Service Center,Raleigh,NC 2709-1636
13a.yield(Rpm) method of test: E'� 24c,Fnr Water SuRM &ipiccHbn GYM In addition to sanding 1ht form to
lbe address(es) above, also subrAh ape Copy of this form aftthin 30 days of
13h.Utsinfection type: Amolmt: Completion of well t:onstntction to the connty health depaton nt of the county
where constricted.
I'arnl(:t4'-i North C.amlitnr t�epnnrnont.�f linvirriammrnl Quality•Division ai'Water ltasoarcee Revfsal2-22-26M

Well Driller Self-Grout Certificatieet
Owner: i ,e_\An JAmctuos New Well:
Address: 1 _T� V2 a Repair:
►
Permit: =r�sv
� „ ; F
ISkV
I hereby certify that the above xdamced well yeas grouted in appearance in accordance with
all County Well rules.
Well Driller. �e-)( Signed:
Certificate#: 2-lt9-
Date Grouted: 21,f
Construction: Gmut:
Total Depth: 40 Type:
Ong T.ve=-P V Thickness: MC 4 ,G
Casing Depth: 14 Depth: c�_)V
Diametor: U Y
Weight/Mc-
Height:
Drive Shoe:
GPM: 0
I