GW1-2012-03831_Well Construction - GW1_20120823

-------- — 828-622-7241 P'1
Feb 1519 05:43p Clearwater Well Drilling
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WELL CO TONRCORDGW-1 c Only:
t. ycqCnn tract or lnfirmation: +
14.WA. EREONES N
tycll C ollwwor Name
2— 1 4 R• A.
ORLi?iER a ntA'rlatlAL
VC.Well Cnntngot cwlficrdion Neontns 1S Q1lTER t%A31NG 10"I TuiCKN
�- l I+RDtt ft rt. `l�' it
Cmmj my Tlamc 16 INNER CASING t3F TtrRp M�� l��'l s NATEp1AL
1rR0?t TOd.Well Construction Permit 9: It. in'
i.lct ali opplicnhle well wnrin relion Pam IX P lflf:Cnnruy,Srnl�lrarin P,elf-) R• to.
3.1VAl llN(Check well uie): 17.SC n AMarlNt a tvICaavCBS 1NATIMIAt.
W,ster Supply Well: Ra R. TO R. in
X Agricultural DMunicipal/Puhtia Q
Geothermal('Hcating(Coolistg Supply) Residential Water Supple(single) t! tl.
Industrial/Commercial Residential WSW Supply(shared) 1&Ggp11f To MA out . sMttiA srHrrn+oo&:'U`to»>sT
Irrigation •' � n. �®
;Yen 1*Voter"Apply WPM fr"
hinnitoring Recovery f t.
injeen Wcll: ft. It
Aquifer Rcchargc QGroundwnterRcnlcdiatinn 19.SANIIlGRr�VBLPACI� [ h1a trtACEhlBtvTM�lan
4nlinity aonier ;'ARDM A AL'
Aquifer Storage and Rccoverp - AL n,
Aquifer Test atormwater Drainage: rt.
Subsidence Control n
Ereperimentat Tcedulnitlg)r rtdexa
Geothermal(Closed Loop) 13Teaccr 20DRlLiiNTLpC /dlachD pairosk pe, see
pRDM j-,
Geothermal(Head n coltng Rtxurnl Other eR lain under t221 Rcmarl;s} ` ir. q R. E
it. ro,
a,hate'Alell(s)Completed:(0�1ail w lnu ft. l
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SO.Well l,nroltinn: �3 R. �^R, 1.ice, �`� �•
Marc
I aeitity:'tluTrriIarrtc Facility[Do(ifapplierhle)
ft
Physicol Address,
City,;Ind Zip ��
��L.t lf9�a 21. ARKS
County Pateelidentification No.(PINI - Ov'
Sh.Latitude and longitude in dcgrees/mimites/secondsordeeimal degree-.:
(ii well field.one 1wMoog is Ardl't Acnt) ® r "9y�rtili an:
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si@nm
enifeod Wcu Cmrtrnator oat
A.Wart)the wetl(s)>�Pet'manent or ©Tr.0Pnrnry n mearl!n oeenrdvnce
Rv al}ming rins.;ornr,1 helnl!v Carib.[hat rhr.twJl(rJ os firryeJ e+nur
i.iy this a repair to anti istiag well: Wes or InNa xx itlt l3A tiCA['n2C..4100 nr fSA NC.AC O?C.'.fITAD We"C,,mrr man gandardc and+hm a
!r'rLir ix n stpoir.fi►1 mrt/nenwn nrll aonun+dlnn ht rowan air e"Pfnin Ihm ann+re r?riho enPp of drts record Aar bran PMv1&lm the well nwner.
r+;anir render c?!rcmnrla,urllmt or on lla hark njllltxlnrn,. 2;_%Ite diagram or additional well details:
),ou may use the back or this page to provide additional well site details or well
R,For Geoprohell/PT or Closed-1 oap GerALertmtl Wells having the same cnnetructinn details. You may also attach additional pages 6110cessery
oanstntctian,onh I G%'-1 is needed. frldicate TOTAL NUMBER of wells
drilled: _ �_ nnaarr-rail IIr.STRtICi70iVS
9.Tntat well dcp0 below land surface: .___.°--'_o _(B•) yta. A AI! Weil : Suhmit this form vvitMn 30 days of comPiapon of well
1'r,rnenhiplrwrRelitrnlideprhxif fiffrmf 0-1nmPlc-3@21)(7 one 2@1001 enngMWAinn10the rollcnying:
IA.Static water level below top of casing: M) Division a(Water Resourees,information processing Unit,
1'R,at r low!Is f*ow casing,axe..•- t 1617 Man Service Center,Raleigh,NC 276"-1617
IL Ron,hole diameter: Lf I�( (in.) 21h.%r iwiectioa we09: IIl addititm to sending the fotat m the addreas in 24a
al)ove,also submit one copy of this form rAthin 30 flays of comPletlrne of well
I7.Well construction method: ` consttMion to the following;
(i C.nusm-,MM•.caw,diroet posh.etc.)
Division o?W�at�Staail gy('UeotdCi�r.�R�atcighi NCt276t19••1 61 Program,
t•�tSR WATER St:PP1.V WELLS ONLY:
13a.Yield(gpm} Method of test' 2,k Irnr W ter 4uDD1.&ioiccHoR H'eRs in addition to sanding the form to
be address(es) above also submit,one copy of Ibis form within 30 days of
13h.Disinfection type:_ Ataotmt completion of well construction to the county health depattmcni of the Gnunty
where constmcmd.
Vann C14'-t North C'amlinnDepnrtmcnt of tin+9ninmrni�l Qnatity•Aivisrnn ot'UVatcr rtaeanwec Revised 2 22-2016

Well Driller Self-Grout Certification
jack on Parms ✓
Owner:. M rLr[(_ New Well:
Address: �t s�
Repair:
Permit:
I hereby certify that the above referenced well was grouted m appearance in accordance with
all County Well rules.
� �Ct Well Driller: � Signed:
Certificate#: d Date Grouted: Ip _3"a
Construction: Grout:
Total Depth: Type:
Casing Type: QVC Thickness: ff- 4
Casing Depth: I QD Depth: C_)C)
Diameter: t `I
Weight/Thick:
Height:
Drive Shoe:
GPM: