GW1-2021-03681_Well Construction - GW1_20210823

f eh 151905:43p Clearwater WellDrilling
WLLL CONSTRUCTION RECORIJ (GW 11..
1. Wel,Contrartorinformation:
JQSh R o,mm S
Well Contractor Name
)(C. Well ^nntrador Certification Number
Cnmpnnv Name
7. Well Cori lrn:Hon Permit i : A \cT ^ 4'5 D
i,lri all applirabla va/1 rnnsrrnmlanlwrmta au, tlIC Cmuuy, Sfo': Yarlrmce, err.)
S. Writ ME (caeca wcf Inc):
Water Supply Well:
Agricultural DMunicipailPublic
Geahcrnlat McMinn/Cooling Supply) Residential Water Supply (single)
industrial/Crommercial Residential Water Supply (shared)
flit anon
Non -Water Supply Wall:
Mnnitaringg
injection Viicli_
Aquifer Recharge
Aqui fa- Storage tad Recovery
Aquiter Tcq
ElRecovery
°Groundwater Remediation
°Salinity Barrier
fStatmwater Drainage
Lxperlmentai Technology ['Subsidence Control
Geothermal (Closed Loop) °Tracer
Cleatltennnl (Hoaingooling Rearm).
ndihcr(explain under P21 Remarks)
4. Date Wdt(R) Completed: `" " Well IDE
S. WMI Location:
Facilit):'f)unerName . _ Facility tthi (ifapplicgidr.)
Ph teal Address, City, nod Zip
Cvnny Parcel identification No. (PIN)
Sh. gratitude and tanpptnde in degrees/minutes/seconds or decimal degrees:
(;i;c1flout,nee lnt1ingfnluE1.315 p t �y�
(©35 A5t.o I�-•5 N Na ui 64.E ,
4.1s(ara) the welt(RjkPermanem or fiTempnrary
7- Is this A repair to an existing wen: EDYos or No
lr'd ie is a rgIafr: fill maknnwvn wen densrrautan it rmolerm and erplfirt 1hr oeuvre q(ihu
repair Filar! f i remarkt proton or no /he Mani' Ihlxtams,
8. For Geoprnbe/fPTor Closed -Loop Gedbermai Wells having the same
tanvintctien.only 1 GW.I is needed. fndicateTOfAL NUMBER of wells
dallied:
�,. 7fotsit well depth Mow land sul7hcty
r�s
For raulrlprrwrits listandlprhrtfdff'ernnt feramplc-3t1141,`mid*I/any
10. Static water level Maw top of casing: (11)
lJ'nwterIntl iR above carhw., afl
ror "y '� e7,C"
i1. flot+ehaiediameter: v (in.)
12. Welt construction metbadt
(i c. mixer, rotary. rabic, iiircct pelt. sic,)
fed
FOR WATER SEPP1 V WELLS ONLY:
13a. Yield (gm,i10 Method Of test:
rib, Disinfection type: Amotmt:
flan GW-t
A
828-622-7241 p.1
I?nr intemnf Use nlY:
W A' :. t NES
+
D' rs..1i,
711.4
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IR
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IS.OUTER
CASING/far °R���fil°aw.
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so
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y
ST r�'
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g
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18AMCl of l WEEP t BS
tecetalat.
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vnOM
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InaTiallan
TRtCRN
MATERIAL
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si_/tEMARKs -- 2rCC��C.
Ce
Signal ! of Canned Weil Commetor
A. ttI mg t'11: fans, !'welly marl) ' that lhrr litdl(4 war (Smarr) r rtinnt'mel lH oinvo ietre
IA? !SA firAC 02C./1/00 or liA tNCAC. 02C:.0200 Weil Cmv/rnmon 9lalahrdt intri thin it
eppp ajthfs room, hap 'Utd11 prntrtavf inMewr!!! rower.
27. Site diagram or additioial well MUMS:
1'ou slay uSe ilic back of Ibis page to provide additional wail situations or well
consuttelioodetails. You may also attach additional pages if necessary.
MI'wr INsTR !t rows
Ma. for AR Wills: Solent this form lvittlin 30 days of completion of well
contraction to the folloic/i1g:
Division of Water Resources, Inihlrmatlol Processing Volt,
1617 MR Service Center, Raleigh. MC27699-16I9
21b. ForJwtertion Walla: In addition to lrtwnditrg the fowl to the address in 24n
shove, site twltmit one copy of this form kwilbin 30 days of completion of well
constitution to the following;
i?!vision of Water Resources. Underground Infection Control Program,
1636 Mall Service Center, Raleigh, NC 2'7094636
24e, JrloWater Snook. & Infection We tic: In addiion to sending the [bon to
the nddmsc(es) above, also submit one copy of this form wMtin 30 days of
completion of well construction to the county health depatlmedt of the county
a h re eofmtllaeted.
Nerd Carolina Dcponmont of tinvinimruxnnl Qttotflv " Division of Water Remmers Rt visert2 22 2at tS

Total Depth: -7(o s
Wig.: PVC
Casing Depth: 73 Depth: 1)
Diameter: £B S
Weight/Thick:
Height
Drive Shoe:
GPM: 26
Well Driller Self -Grout Certification
Owner: M 1 U' I G i 1 Co' itYlan New We11:
Address: Zfl t IGn© civ o2. I44; r:
Permit CI J i3 1 u 11 G)
I hereby certify that the above referenced well was grouted in appearance in accordance with
all County Well rules.
Well Driller: JSA harems
Certificctp#: (413 7 - A
Signed:
Date Gro
Construction: Grout:
Type Cefilejj
Thic1mess. IYl ' d