GW1-2022-09883_Well Construction - GW1_20221028

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Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 p.1
WELL CO1wTST[tUCTIONkECORD(G41V-Y) For Internal Use Onty:
1.WslLfiontraelorinforinatlon:
14.WATE ZONES
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it'cllfiartrraurxhfat� Ie. ft.
V'NrcllCnntrannrCeRiRca►ionNctml>e1- c 13.O11TERt:ASING formoifl•asedt+ve)Is IDRLt?1ER ifa 11te
/`� ---' i+n'A7 ft. �� �• DIAflSF.I /in. •rI1ICXNFSS MATEniAL
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GnarpanyName �� r[6.MNER CASING ORTt'HING INrDrmatetmedlgo
2.Well Construction Permit k: i Oft TO DIAMETER THICKNESS INA tUAL
i.lrl all apt iira5lc t,rll ermrrmdlan pzmrfrc(l r U![;Camxy,SIWG Ifat9m,rc.clwl ft IL in.
3.IVcll Use(check hell use): n' R ,a
Water Supply Well; ra SCRUEN
M. OM ITO brAMETk9t SLOT ME THICKNFM MATERIAL
Agricultural MunicipalJPuhlle () tt, ft_ in.
Geothermal([TcatingfCooling Supply) Residential Water Supply(single) n: ft. in.
Industrial/Commercial Residential Water Supply(shared) ISCROUt
ltri^DtiDn FRAM70 IqA L EMPLACEMEAT34WM0DdcA1:rOUNT
Nun llnterSupplyfl'ell: ft. `� fe, Man
Monitoring Recovery t1. fr.
Injection Well:
[I. R
Aquifer Recharge 13Grotmdwater Remediation 19 SAMJ/GRA L PACK i[o lieabk
:Aquifer torap and Recovery E,S3linity Bartley PROK TO MATERIAL HiTrWCEM118MTMCtItOD
Fif
AquiferTcit QStorrawaterDrainagc
Experimental Technology fjSuhcidcnec Control
Geothermal(Closed Loop) 137racer 20.DRILLiNGLOG dtschal onsti m fi etsifDesary)
FRONT TO UFS'CRrr'r'IDN mror.h Aeeo.wlV�c4lypr.xraH+,Fzr,ete.)
Gcothemlal([tcatin Caoiin Remm) Qlher(explain under#21 Remancs) (
.1- 9 R.
4.Date Well(s)Completed. Well IDY - i _
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54.Well I,ncnna -qcatt_ 4D tLQn: _ -
PI.
lscilit,•:()nact?tame Pcility tog(ifapplicable) SOLfr. y5
RiAhe"Vfosd-
irst Ar'.rlras Citp•attQ?.ipa 21.RFMARKS
County Parcel[d ntification Na.(PP1)
{frivtirc .
5h.Latitude nod loci itudr in degroadminittesiseconds or decimal degrees:
(ifaollfictd,are
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6.Is(arc)the welts) 'crmnDcat or ©Temporary Sign ar oECcrtifirdWctlCaatmeror Date
l;v.at inf,riiLa;arnr,I herrr!v ccrflb:drat der tvrll(.j xvr;FacrvJ crmsrrarJur fa accntdoncc
7.Is this a repair to an m asting well., Dyes or No 11*1 1SA:,-rAC D2C.nIUO nr]JA NCAC'02C.'.0 un it eaCwtslMcnair Stotulards anti ihara
/;'ddrix:,rc/toirfillmebiannnrll.anarrulianuljanwliaamur pininlhr.narun•al,hn enpj.afrltirrrararlh2el,petprn►fdehilnrltc well atvltrr.
nf,wir under t21 rempr cr srcarir or on ilw-hark of lhisfamt. 23.Site tliaRrltm or addidonal well details:
R.For Gcnprohe/IIPT or Ciacerl-1 anp Ceothermni Wells having the same You may use the back or this,page io provide additional well site details or Weil
rxtnetnrctinn,onl}I CAV-1 is needed. Indicate TOTAL NUMBER of wells eonstructinn details. You may also att&Dh additional pages iftiecessmy.
drilled. �[IBMft'i AI.1Si5TRUMOM
9.A'41a1 well crcpth trctow rant surface tO�T 2•1h. for Lfl W_eDs: Submit this lalm within 30 days of completion of well
lrra+rrhlplc wells 1AI"lid.nracrf&fferertretamnla-J@xt?"and;@1007 ennstmetiontothefolloletng:
In.Statie water level below top of casing: (R.) Dividon of W ater Resources,information Processing Unit,
tf xal'.).Arel kfkacs raclag me"--l 1 1617 Alai!Service Center,Rate[gh,NC27490-1617
111-Boreholetliumeter:L!/` (in.) Trlh.FDr Isle Lion k-1 In addition to fending the form to We addrm in 24.1
IZ Well construction method, al}ove,also submit one copy of this form•vilhln 30 days of completion of well
construction to the following:
(i c.auger,mCccp.wGle,direct push,etc.)
Division ofWater Resources.Underground injection Control Program,
FOR WATER SUPPLY WF.LL3 ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
13a.Yield(gpm) illethod of too, 2.rc.irnr VYnter Supelc&lniceHoD Wrettc In addition to sanding the form to
the address(cs) above; also submit one copy of this fotol within 30 days of
13h.illsinfectian type: Amount: completion of well construction to the county health department of the county
where connected.
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ForniM-1 Worth CaralranDcpmtmentofI-n.9mnmcrtalOnalil -DjvistorlorWaterRcyat:rcec Revised222l016

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Well Driller Self.-Grout Cord"coion
Owne
Address: r ►,Fur.
that the above reduced weld wrS grouted in aPPeamQe ir,accordance with
all county Well riles.
Well Driller: j-cv�-A Nemmm sip
construction:
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