GW1-2021-03679_Well Construction - GW1_20210823

Feb 1619 05;43p Clearwater Wall Drilling 828$2?_-7?41 p 1
W EL,L CONS UC, ION gECOl fGw x� I or intemni Uae lily:
n Am im
Shell L,cKI"ga'J�vamr
VC:Well Cantrapm CettlftenlfOA Nufntry (\�) $19i17 6R +
\✓ Ut�M � IA1.
CnminmyNamc yy � � '�� t
2.Well Conntruenan Petwoll R: .� R To 06 EMe4C� t NA
!.braid Pa►Rl
aJy+lirnhla rvelterme+merlon !U pu f/!C,GnrmrX,Slates Yartancq ur.1
n., tit in_
3.1Yrt1 IF'ir.(check well list):
wotet`i+mpply Well: 1 Ro Ic ttss a1.
Agricultural DMmliciollIftblic () 0. n-'Nfi tp'
Geahcrrrtal Ioatip VldeWIAl Water Supply(single)
¢ g1Comllttg�tlppl;�
[ndustrintiConu,l=lai t3 Residerft Water Supply(shalvd) OUT
MMT L 81tt Q 1Q1'
(rti anon � � r1I1
JYnn-VI'nttr Supply Vl ell: \ V �
Ct4onitotin RCOOVMy to &
tnjeeHom li: p, R.
Aqufiet'Reellne E3(lroundwaterItemtdintion ]9 L A
AquifcrStWgc tmd Recovery E]SAWity Bltttiv - ltR L c ton
Aguilcr Trst 13Stormwom Drelpago n
Experimental Tedinology QiSubMdcncc Camrnf tt'
Geothermal(Closed Loop) DIcuet
Geothcrtnal Hatttio lint[Raten) 7Ottttr(axpluin tinder 1121 Rcmarlcs} tt, nIr
A.r0xft Vdl(a)CoWleted:, 4-�" (�I well ID9 --
Sm.Well iLncnHnn: ft. CC-
J�sttlity,7)tract Fadlity[Dil(ifaltplicplde)
CL
P\hysir�nl Afldraax,Cltx,an^d zd-p,
AR
Cvuny Nreal tdemiileation No.(PIN)
Sb.i.alitade nod lomAfitmde in degreeslodnatcslseconds or decimal degrmn -
(ii,,Von fretd,one Intilangin Summit") 7a CerKfiieation:
6,ls(ttre)the Well(nj erfmaoerd or ©[hrtvorgry Sign u=arrollfialWell
chonzate, owe
/}v.rrprrarg+laR into,I/lgrally rmrtlfj,that Air.IPWAJ,mar(Sror,r)+1p)ffMIMd fin attv,►d4yrr
:.tdt4isarcpAlrmanexistingweft: �Xcs or, `No rr%lial.4.W..:ACOX:-9/ODorMA,YI:AC(12t'.IlXtOWe[iCrmrlfncnor+9tat+rMrekmrdthm+r
�d,trls:asyrvfr.J111m,rk+mwoWr./loonern,atm+i,�imallatandnrp[einlbc,u,tanrnf}6u �I7:'afll+dab!cardhaskrtxprol'tdtMllnrhL'1VPJ1Atvlfet:
mwir rmder V1 mmarkc grmm area Iln:bant of this fami, q,•L Stla db kgram or additlormt wag dtmdLa:
8-For Geoprober'APT or Clowd-L.tmp Geotbar'mal Wells having tha same 1'ou MAY use Utc back of this PW to prAvlde addititlrlal vdA alto dalaik or well
gction,only I GW1 is needed. fndieam TOTAL NUMBER nrwclis QX15trut:litxtdrlailS. You msy also tMfth additiorutl pRge&if noeeseaty
onntm
`l•Tim"welt depth below land aatlll c ��� to) 20, e'er Aq_3M: Submit thl_q fora wi ltin 30 days of completion of well
FnrmnlUplexrlhlitralideryrlieiJdtB'arnor(ermMrlu-3(nl)Ofl'ardFQlan'y cowl pjontothefalltwft:
P.stet➢e water kwcl bftw top of taxing. (ft) Dividon orWater Renate 1pihrination ProcMieg only
gfs'arerhrwt is r4we cwny.Inc 1619 Nfaii sttrrvke Center,pxftb.XC.27d 4-1617
li.Rd►lehole+tlnmefcr: `\ (in.) 24b.For iwkctioa WeLfa: In addition to sending tits fang to Ste add=ill 24a
ahavr,>slflo su mSu mb it One copy of this form within 30 days Of COMP101OR or well
12.Well;constrnetlon mashed; _ �� ., c"#tuetiOce to the fallowing;
(i c.Mille-,way.arab)e,Itim ptteh,SIC,)
Dlvislan ofWater Rettwtrm%Underground injwftn Contrpl Psogram,
FOR WATER St:PPLV WELLS ONLY: � 106 Mail smvioe Ccutnr,RAtelglt,NC 27609-IGM
131/.Yirtd(gpm) Method of lest. 23c, t-r &toroeMon rJNe11s: in addition to mttift the ib m in
1 the nddIvsKes) above: also subm(t rM copy of this form wld&30 days of
113b.1111sinrretian type:_,. _,�, ,, Amamh completion of wall consisudion to the conuty haft depadment of the county
--- w7farC caaxRRmama.
rant CW-t manh CAmlinn DatIvament of Envtrrininrxnni Qv,Nity•Divisrnu of wawr Rmrmitt•as Rev[suA3 22-20I b

Well Driller Self-Grout Certification;
Owner:
C(Ly C)����1 C'IQ�V`t;l New Well: y
Address:l01k0 UJP%k le`�.�-� � Repair:
w v
Permit:
(L `k1�J
I hereby certify that the above referenced well was grouted in appearance m accordance with
all County Well rules.
Well Driller: . )o5h � BLS Signed:
Certificate#: `-fit 3-1 -N Date Gr ed: �--1-a 1
Construction: Grout:
Total Depth: 3U<�_�Jr Type: CeYYV-Y` +
Casing Type: QV C Thickness: (-n�4- SL
Casing Depth. t--60 fi Depth: �+
Diameter: LP.`t
Weight/Thick
Height:
Drive Shoe:
GPM. 1