GW1-2021-03683_Well Construction - GW1_20210823

828-622-7241 P'1
Feb 1519 05-Ap ClearwaterWell Drilling
WE'LL CONSTRUCTION I2Ett,0 {GW-1 l Fnr intctnnl Use Only:
1,Well Contractor Information: _
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2.Well Countrnetion Permit#: ft.
i.lst all oppiicahte well canefnrnfinn partafrs(l o.INC,C:oan y Smft Varinnrr,crr..J
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Agricultural Memicipal/PubRe A d'
Geothermal(Heating/Conling Supply) Residential WRICr Supply(single)
IndustriallCommercial Residential Water Supply(shared) IS.GROUT
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Nan 1'1'nrer 5uppiv Will.
Monitoring Recovery _
igjecticn Well:
Aquifer Recharge E3GroundwatcrRemediation 19 gp)MIGRAVSL PAC It Ea e
Aquif,xStorilge mid Recovery .Salinity t3Rrtier _locos[ TO ATCRIAL TM
tt- fl,
Aquifet Tcst [3Swrmwetcr Drainage --------
Gperimental Technology
5uMidencc Control ft. R"
Geothermal(Closed Loop) E3TCRcer 21k llilul.i.1NG LfJC rtl+cbD aletteetslfttcmle a�mcR graw3w,610
FWV To
enthmnal eHontin oo1;nR Ronum) other(explain and 1121 Remarks) ; fr. it.
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d.Rate tYdl(s)Completed: _-dwell I Dll l
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vacilihs'(lwner# Facility li)il(if applicahlr.
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51).Latitude and longitude in degrexslmhntteclsecoads or decimal degrees: t�Gll ONp�g J
(ii�w:ll field,one tatflona in sufiieientj, :!3.Certifmu ' n:
0lJ7S" %S-zI IV 7
l,.ls(um)the wett(x)Itpa•manent or ©ITempnrary :i r olC.anrried Wen Carttrnetor Moto
"TT�` Y• ,`etlming rho.;rrm,I herrhv c-100:that rile I ddl(J —fWam)a marncrad in anardrrrcr
1.1.this a repair inanexistiogwell: 10Yes or o ,!flrlSA.tit..'.ff.:02C:.0100or15A,YCAC.02C.'.0200rlrrgj&mrfrnra)a)r57amlardsrtn,lthat.r
!''rlitr7xer))pair.fell mrrA�mwn uv,ff.:anxrrnctimr nffnrmafinn n1 crpro)n thr.mane nf)hc [nptr nff/rts canard harhem pmv"In the well Mv+ur,
r va+r rmdcr A?f rCnMrAr Suomi or rm fill!bar.ofthis fara). }3.Site diagram or additional well details:
R.ibr GMspraheflltt r or Clnced-I anp Geothermal Wells having+hc came 1'nu may use urc tuck of this page to provide additional well site details or u -I)
aWlT rction,only I CrV 4 is needed. frfdicatc TOTAL.NUMBER of�.r:lls a)I19tructinil tlrtails. You may also attach additional pages if necessary.
1fJ�AT.ijti�STRttG7tONS
9.7'nt2t wale depth 1>Clmr land surftico; __(M) 2,1.a. For Ail Wt h.- Submit thin f0fM within 30 dRYS of completion of well
1-rrtvidapleweicell!alidepfhejdijferrnr(crnmple-3Lh11n0'and2@10a) comtruiXiM10 the following:
M Static water level below top of easing:_._.� (R-) Division of Water Resources,Information Processing Unit,
0 filer h-'rrl is rd avil Casing,me •" 1617 MAII S"Wee Center,Rote igb.MC 27b99-I617
il_Itareholediametcu: [� C/dt (,^n.) zsb,FM latecHnp Wells: In addition to sending ft form to the nddiim in 7411
2 1Vclr cnttstructton method: /f�4t, _ al`ove,also submit one copy of this form Within 30 days of completion of well
1
1 C.Welangel Minty,cable, 2irm petsir,etc,) canstt etion to the following:
Division of Water Resourims.Underground Injection Control Program.
MR WATIER SUPPI Y WEILLS ONLY: 1636 Mail Service Center,Ratelgh,NC 27699-1636
13R.Yield(gpm)_- _ iltethotl of test- 1� 24,-_ For Writer Suneiv&inieeflOn Weit¢: In addition to swMing the form to
Me frddrem(cs) above, also submit one copy of ibis form within 30 days of
sib.Disinfection type: Amount- completion of well construction W the county health department of the county
where constructed.
Donn C lk-I North C.nmlinn f)epnamcnt of ttnvimnmenral Quality-Divisrar,of Water Pmanraec RemNed 2 22 2016
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Well Driller Self.6rout certification
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owner: lZ Acltlress:L.Dno r
P"dt: sAs ►Z.e4+k1 ..
oe in acoordanae with
I hereby cff*that the above referenced w&was grouted m�
all County Well rules.
Wed Dryer: signed.: "-�
C�cate#• l 7--A- Date Gro
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Construction: Gmit.
�a� Type:
ToW Depth:
Casing'Type. C-----�
Casing
Diameter: �B
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Hdght:
Drive Shoe: