GW1-2021-03595_Well Construction - GW1_20210823

Feb 1519 05:43p Clearwater Well Drilling 82$-622-724 P 1 '•..
WELL CONSTRUCTION RECORD fGW-1.) For In(emnl Use only:
i.Well,rontmcwrInformation:
WVV �A AT ZONES --
pnAM 7A DBSCRIPi')AN
Well C:olimm Name
WellCnntmClorCettitt cation Number I S OUTERCASING ffOramitltssedwells ORLrM n
C DRAM M D1A 71ItCKNH89 .�
C:nmpnnyN;rrtc ,_n h n �o�/� �i6.IlYPIERC I <?R'4't�iM11G thormntclated-!oc
�)��Y��,J'`/! � vl 7A DIAMt:[EA THtCA'N6S5 NAZSAtAL
2-Well Coantritcoan Permit#: tn.
i.i.rr aN airy iirn5fe weJJ e......aJnn parmfis#.a IA(..Courxy,Stab Yurimwr efe,j fl. ft•
3,Well Vie(thetlt wd)use):
17.SCRBSiV
Water Supply Weli: � m DtArosrtau suorsocs 't'xu:aayssa [tr,�TehuL
Agricultural Monicipal/public Q tt. ft. K
Gctxhermal(I•iesting/Conling Supply) ftReddential Water Supply(single) O f in.
[ndustrial/Commercial F3Re3idcnti2tWAWSupply(shared) I&ORO, .
iT-!anon rpm T MATERUL SMPWCB `ira1B7�N}PAAMAUTtr
Nan�►'nterSupplywrll: n" R' l v
Monitoring Recovery
injection Well: -
n.
Aquifer Recharge E3Groundwoter Remcdiatinn
l9.SAN1S/G1tAVSL PACK if o ' e
AquMr Storage and P"Overy "Salinity(3n[ritx t+ItoA[ TO MA L iflMVLAC1NBNTNC17tOA
AquiterTcct 0Smtmwtlt+erl)rainagc A'
Experimental Technology [)Subsidence Control fl. n•
Gcother[nal(Closed Loop) �Tcacca 20.tIRIi.T.I[VC L(1C d1ael►re! at i tanoetse
PRAfT TO D rotor. raliao anWroehf Ina dr.
GcothcrmM(Hcetin aolinA Rcmm) Other( lain under f121 Remarks)Jf fit n it
A.DateUlem(s)completed: L,well my s� ft- ft.
��, fit ` — 2
.riu.Wcli Location: _
rt. WN
Facilih,10"er 1,hrrn Facility iDd(if attpllcabt.) A. ft. \YIN
RQ ' V V _ fir. &
sir.!ArtAret:s,City, net 7' �} •� / �( h'
xt.REMARKS
Caunly Parcel Identification No.(PIN)
51).Lntitudc and lonjotade in degrees/minutesfmconds or decimal drgree-, -
(ri.yell(eld,one tagangi�s su tlx'icm) D O l!2.CertiGon:
5
a � v 7-
b.1s(um)the weli(s) manent orDTc-mpnrary 1' Wee ofCaliried Well cantrnetor Data
.r+}Ming+hls.;n»n,7 huvJ+verrrlfj+Ihal the tvd/(4 tmr(WeT4 comon clad en arcnrdarcr
7.1s this a repair to an existing wen: OTfes or JUNo a•JNt JJA.ti<'AC.'A1.( .?I00 nr 15A NCAC A7C.'.0200 Well Cn+egrnrnnn S+onrtanLa rmd+hnr n
11,Jcicn repair ANonrknawntic+/I.vo trixuanirfntmaitnnmtdrrp/airrncv.nnmren(the tapjtnfilrievery)rdk'bra pmOddin the well nivner.
n;'air Mdrr R:f remarb senior arm the hnrJl afthlsffarnt.
}.i Site diaRnro or additional area dtltatis:
R.Ftir GmproheMPT or Closed-lenp Geathermai Wells having the same You may use titc lank of this}rage to provide additional well site details or well
w.nslntct(an,only I GW-i is needed. 1'rtdit ata TOTAi.NLiMBER oi,%r.)is e+)nstrueiion details. You may also attach additional pages if necessary•.
- -- !Q � TJAr-I M UTOS
T4tai ell depth IXIMv land surfac:
1,1 t for AN We)fc; Submit this fDTM 1ri0tin 30 days of completion of well
FarneaJ/IplenYllellva(i�:prtuifdij(ermr(exaMPk--7O1(!0,anef2 0001 Construction to therollov":
30.Rtn6e water level betow top of essing: w o (ft.) Division of Water Resources,Information Processing Unit,
ffxvtlt'r•lcrr.,is ezhavernsing.Inc 1617 Allah Service Center,Raleigh,NC274"-1617
I1_Poneholediameter. l56 ( (iin�) / ],eh For iwicction lYctls: In addition to sending the form to the ad;l sls in 24n
12 fYell cmistraetfon method' 1 lA/►'�I W ovc,also submit one copy of this form within 30 days of completion of well
I C.nn c,m, Pe ' aamsitnetion to the following:
8 ttt5.a�blc 4im-t 15h,cic.)
FOIi WATER St.PP1,V WF.I L4 ONLY: Division of Water Resourm%Underground Injection Control Program.
1636 h4nit Service Cantu,Raleigh,NC 2709-1636
13a.Yield(gpm) Method of test: ty�G7 Ve. For W'nler Sunnily&iq�Hon Wells: to addition to sending the forth to
the addtess(es) above, also submit one copy of this form within 30 days of
s3h.Disinfection type: .Amount: completion of well construction to thc cosinty'hcalth department of the county
whore constructed
I
hnntlGl4.1 NaAhC'amlrnnDepnnmcnt.�ftimimnmanr�lQ"alit.-AivixtanoewamResulaces j Revised2222616