GW1-2021-03702_Well Construction - GW1_20210823

828-622 7241 P'1
Feb 1519 05:43p Clearwater Well Drilling
WELL CONSTRU,�TION>I2ECORI MGW-111 For Inte mnl Use Onty_
t clt Cnntraetnr information: ,
Mead o wS 14 WA—EONES
trROM Tn pa9CAtPrION
Well C.onaraclor Name fill.CD
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NC.Well Cnntmoor Certification Ntonler p S 15.OUTERCASING nmtpeasidwtmt�Tllt a ltitrTtatuL
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tr. •
C:omrtnny Namr. 16.INNER I ING OR TURING tfiermitl dwelt-loo r
ACKA 1-40 J IR m TO DUMP wk TAt MAfF�UAL
3.Well Conatrnetinn Permit#: fG ft. in.
i.irt ati nprlicaAle well enmvinrerian parmns(La Illt:.Cnnaly,Ste/a YaNtwev.air-)
fl•, $. ia.
3.1Wc11 iisc(check wd)list): "t7^
►Pater Supply Well: ittiotut tt► u AtNa7F'at ' sMwT=[Ak-
Agricultural D.Municipal/pullk t* n-'Iff a"
Geothermal(H ating/Cooling 3tipply) Residattial Water Supply{singlt) Il t+.
Industrial/Commercial []Residential WgterSupply(shared) 2& 0
p�,yt TO MA RUL EMpLAC •tr?t'aa71tODJlsAMO
lrrisotion - rt^ l d
Van�1'ntcr:iupplywell-
t\4onitoring Recovery f+^ fc.
fgjection Well: ft. R
Aquifer•Recharge E3Groundwater Remedistion 19 SAN19lGRAVBL FAC[C a
aquifer Storage And Rccnvcry Dsa6nity Barrier m A717u L mart.+ 8et�rttttrttan
Aquifer Test [3Stnnnwotcr Drainage f fL
Lxperitnental Teeltnningyr Subsidence Control 0^ B.
7RZicotliermal
othermal(Closed Loop) �Traecr 2a,ilRiiJ.1NG L raUaeh at ° "° wtthoeh+ rapt aiap deer
(Hcatin Coolie Return) 01h9r ex lain under f121 Remarks goat ro
it. ft
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A.)daret►'e11(s)Completed: ®� r well INft. -7 t4
Su.Well i.ocation: d t, a�
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a O R,
57
l acitityrttnmcr Ito Facility tDil(if applicable)
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y� r(,i K X G9 I t^J R -- ►lip
Physical Address,City,and Zip t �-
/y 2l. ARIC.S ,
County Parcel Identification No.(?N)
5h.Latitude and longitude.in degreeslmimites/seconds or decimal degrees:
(ii%ve))field,one lntgoog insufficient) t 22. �er77-,�
:
6.ls(am)the well(s) Permonent or )Temporary Signativc of C.+)fled Well Ca"wor oere
w \ Ifv,vltming rhls;imn,I hetwhv cart/h-'that dhr.MANwti(wnrM)cimvnw&l in oenardnarce
7.Is this a repair to An existing well: "Yes or OjNo Rath 1.S.1 SCAf.�VC..9100 or'15A NCAC.4)2C.0200;vetj C,,nsrrncnmr Stondaniv mired ihnr a
1,r'drrr i-a repair.fill awrMtaum nvdl.onetrvctinn irrfnrmalion mrrlTcpinin the nail,".?rlhc ennv nflhrr n rand here bran ptotKrin In the Mw mvner.
rravir order F:1 remnrlcr arac0mt nr na tla:hark of fhb forin, 23-site diagram or addidotml well details:
8.rilr GeriprobeMPT or Cased-Loop Geothermal Wells having the same lion may use the back of this page to provide Additional well site details tir well
txnsinrctirrn,only I CAV.I is needed. rndicate TOTAL NUMBER of-wills ctmstruction(details. You may also attach additional pages if occessen,+.
drilled: SIOMKIIALi SlRiit' ONS
9,Total well depth Now land surface: _(44 M. Bar Ail Welts: Submit this form within 24 dads of Completion of well
f%amuiIlipfeweN.,liont,drpthr,jdoerrnr(rrampte-.@200•and2@100) constrMirmto the follmving:
111.Stode water level below top of easing: lull ! (0.) Division of Water Resouru. %Information Processing unit,
IJ'R ntr.r;c+id isrrhm cns/ng,nee'.," 1617 Mail Service Center,Raleigh,NC27dWI617
11_Borehole diameter! tX✓ �` CIA.) 2 b.Igor Jaiectina Wells: In addition to sending the form to the address in 24a
12.►felt amstruetlon method• above,also submit one copy of this'torm within 30 days of completion of we 1
ct►rlmiation to the foilowing
(i a augc,mhrg,cable,diret�t push,etc.)
Division ofWater Resources.Underground igjection Contra))Program,
6tOR WATER Sl PPJ 1i WBLLS t)NL Y: 1636 Mail Service Center,Raleigh,14C 77699-1636
13a.Yield(gpm a) J Methad of test: 24c,,(;Lr Witter qllndv&fofccHan Wefts: In addition to Bonding the forth to
ibe address(es) above, also submit';one copy of this form within 30 days of
fan.Disinfection type: Amount.. completion of wall elm miction to the county health deprmt ent of the county
where constructed.
t'mnt GN+-1 North C%wlirm Department of I.-Horonmcotnf Quality-Division of Water nasaateaa Reuked 2 22-tot 6