GW1-2022-09752_Well Construction - GW1_20221027

828-622 7241 p.1
Feb 1619 05:43p ClearwaterWell Drilling ,
WELL C0 NS'I'! TJg--ION 12 WORD M-1) (�5rintemnlUse Only:
1. rllQC��/ntra�t�r Informatlon•
e ZONES ngacwrcloM
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IVrlf Contractor name
v({C.,'welll Cantmclot Catification Number S OUTER CASItVG fottnotA cued vietitr ORLf?lER a hab[e
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� DIAtNECf3t TAIChTtFSS MATF.IUAL
?Well Construction Permit Ih ft ft In.
N'o all appiieable welirnnttnrcilnn paam0s(1.+:tllC.County,S147e,Vrrrrant:c,ate:)
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3.Wdl lltc(check wen Usti):
IT.9CR8 IV
Watel•5npplYWell: ra nwnatzr[� sr orstacs rntclnveas T&RUL
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Agricultural DMttlticipalMublic 0 R-
t reathcrmal(kleatingiCooling Supply) nkelidential Water Supply(singic) n• tt- in.
GtdusiriallCommercini ResidcntiajWatar.%Tply(shared) laCRplli
6Ti anon tROM 7o MASERGL 1Kar6%1; Mts.�(rr. Mnton&At+rotrrtr
Afanitoring Recovery ft. ft.
Injection Well: fa R
Aquilerltecbsrgc QGroundwatcrltcmcdialien l9.SALVO/GRAYSLFACK ifa 1 I
Aquifer Storage and Recovery Ds dinity anaier BRom To MATERIAL �ttrincrnta,nTMc�nan
Aquifer Test OStormwater Drainage !' n.
Experimentai Teelmology oSubcidenee Control t►•
Geothermal(Closed Loop) [3Tracca 20.pRIi.L1NC LOG attach d Islteats naerse
eeoVr To IlE& 1oN rotor. tnitrteettr ralM,kgrrrr.
Cicolttermat(Kcatin Cooling Retuntl 7 Outer cx loin undo i121 Rcmarlcs) ft m
-mot 1 —22
.f,Aatc,1N c11(s)Cntaplcted; 1 r ft.
Sir.Well Ioration:(�Mon R en �\U`w wo
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Physical Address,City,and Tip lkl_s Y1•REMARKS
,`l�' ad Son nr 9
C,nnty panel identillcation No.(PIN) -
51).Ltitltude and longitude in degnmslmimNes(secondsordecimal degrees. t 1n ,;,i,;�� r r;�<; U i j Ur44
(iNveltfield,analatliangissuilicicnf o :2.0 i(irntinn: Gr:'"Qi 3
W 4-T 55�'
6.Nam)the wdl(s) cvmanent or ©ITempnrory sign artil;cdwetlCantraaar Dale
.0p arming flax m,!berrAt usrrlfj/hat roc wdl(a)war(warm c+mar+urra d 1n aeonrAntrce
7-is this a repairto an cXiYtipg well: yes or No vrrA 1SA tiG'AC 02C.r7100 or 15A.YCAC 02C.'.0200 Willi Canarrncnaa 9andarda and rho a
;Dour 1-er repair,fill outllttMwn:wJf aonstrrrettmt inprmatrmt Ad crplairt the immure nrihc copy riflltic rcrnrrl has he+9T pMtddeut rn rlu:wi(1 ntutrrr.
r:raairmtder Ut remarla,5ccann nronahchMrkoflhtrfaun.
13-S11C 11i9gf7m or additional{iCI)de'1RiIS:
R.For Gcoprnhe/DR r or CIRs¢d Lnnp Geothermal Wells having the same 1'ou may use the lack of this page to provide addidona well silo details or well
MR91niction,only l CrW-1 is needed. indicate TOTAL NUMBER of-Clls co��ion cictails_ You may also attach additional pages if ru eessery,
dt9uari:�__ _ �ut:rro�s
0.TOW well depth below land sudacc: � ._.14.1 2�ii:t. for It wells: Submit dtia form within 30 dnvs of completion of"wall
FMr fit OripreweasJasli Ccsnmole-3@140'Vila 2 10011 cnn.9lrucdonto the foilolling:
1f.Statie water level helow top of casing: __________(ft:) Division ofVliater Resaiwees,Information Processing Unit,
If a ahrr Aral Is rkare caring,rote",•'I 1617 MAR Service Center,Raleigh.NC 7..76"-1617
11.Borehole dinmeter: LP
t f (tn•) 25h.Far IAicction 3Y¢Ns: In addition to Sending the form to die nddrew in 20
1 /� �� aiTove,also submit one copy of this fortn within 3n days of eompletlan of Well
I2,Well constn � 1 w'allom method! .,+ canstruetitm to the fallowing:
(i c,mrg�,rnnq•,cabJc,4lircetpttsit, c.1
Division of Water Reaaurcei,Underground injection Confral Program.
F 0 R WATER SUPPJA WW,ELLS ONLY: f1 , 1636 Mall3et•vice Center,MOP,NC 27699-1636
13a.Yield(gpm) t Method of test: ,j�t� _^ 24C.Irnr Water cunoly g>iaicctian-_ dt� In addition to sending the farm to
the address(as) above; also submit one copy of this form Widen 30 days of
fib.Disinfection type: Amount: completion of well construction to the coimly health department of iho county
where constructed.
Farm Gw-I North Cnrnlimti)cpnnmmu of rEnirrinmcahl Quality-Annsmn of Water Roactmes Rr_vRM 2-22 2016

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