GW1-2021-03757_Well Construction - GW1_20210823

828-622-7241 p'j
Feb 1519 Q5;43p Clearwater Well Drilling
W ELL CONM"jM0N I nr Intemni Use only:
I.Wdt ntraetar Information: ,
pIaDN ?P Cli9 Iifid '.
Well('ontracnx Nome (t ft..
VC:Well Cnmmejut Cafification Numbw $,Q>jTt SR CfS1PIG tta•1 a
\Aj b� k../! g. �AMaix,R MA1TRUlL
Company Mama 6.WNl;R CAS NG aR 71t81NG gtotmal e !
>Ra TD DLMt:t'H't ' 77R NAtt€R1AL
2.Well Comttruetion Permit p: Et w in
i.iv(di of diW'tIft,well rn TIMC11ott/wrmRs(!.0 4fa Gnnpry,T1W' V�—a.air J
n. tc tn.
3.Well Ilse(check well list):
Water Supply WcR: 17 srvT. rnmatresa ?BptAi.
Agricultural �Mtmickpallpubkie O rt• fL
Geothcrnla!(kleatiltg(Coct{'ts►g Supply) csidentiat Water Supply(tingle) R- it tD
lndustriaifC,ommereinl fjResidemiai Water Supply(shared) lg` p .D M aa�Aarotltrc
Irrigation t�ttatt TO >tia t, zVM
rt, (9 fD ft
'Jnrt Win ter SupplyWrll:
A4onitoring ORecovery to fa
inlecNon Well. FL R
Aquifer Recharge E3froundwatcTRcmcdiation �S 1BLPACK la
Aquifer Storage and recovery DStdinity Batrier RON TU NA mvtrtwerins Mc+naa
mnuwow Drainage n
IL
Aqu{terTcst � _..
Experimental Tcehnology [3SuMidcncc Control (L R'
Geotherinal(Closed Loop) Tracer M.DRILLI CLOG toter. w4dre.eu.t --
PttOPr 7'a
Geothennai(Hcetin tin Rcwm) '()der ex in tntderB21 Itcrnnrks) ft• b tt o-cj4r -
s tr. rr.
.i.Date U'4l(s)CoMpletcd: 1 well[t)t! r► (k ,
Su.Well Lncttfon: 4
(I1-acllity.ilancr
Facility tDri(if applicable)
`- rt.
P�U, A psicul(°A�, �
ddr�aas,City,and
�Zip 2ti• A�,S -
sn
Camay Pnceal identifteation No.Q N)
�e
Sit.LANtude nod longiltade in degreWmimitesfsecondsordecimal degrees;
6 we l rretd,anc IatQong in sufficient) a I 'r2.CeAittcation:
0 1�(C_I -D-1 3 N MO-S Ts- i W V, _'_ ^—�
Sspnai.r.:of Certlriod tNdl Contractor �P
6.ts(ure)the welt(s) Permanent or DiTentpnrary root eke nvJl Mar fxaru)coanracrcd m aeon cr
lrL alF►rin$Utls;urM,!herrhvavrtl/Y t'�
i,Is Ittic a repair to an exiYN WCII: Yes Or GtYo +n+rp 1SA tif;',r{'A2C.R10H nr 1SA N(.AC AZC;.OHIO Weft Cnrxtrrnrriaa 4tmrrler�Je artet ihm�r
p Grnv lift@!r ntmrrt hor Ah9t protdderlln rfx Carr(/nwltu.
1014-T is a rqr 'r.,(!11 oraknown rvoR.:a onxxlon inprmmien and csplain 7Lr,limn-I!r hu
r:pair under Alf remarks xVion aP.M 11rc hark of lhis.fomr. IL&--t diagram or addidtind well det:a{Is:
1'ou may use rite imeic of this page to provide additional well sits derails or well
R.For G¢olsrahc/DPT or ptttctd-,.amp Geotbernm!Welb having the same �y �rAion details you may also attach addititmak pages if nocrssarY
uxmatmctian,only I GWl is needed rndicato TOTAL NUMBER ar.%Vclls
drilled'_....__ _ _ ru1 :m,r tn^STuf'IYt1NS
'!.Total weft depth below land surface: ( ) 21a Fa AIt W&. Submit this form wktltin 30 dasm of completion of well
Far raidtip+rewrilelAta(idrprluifdffannu(rxmoPk-4)"tranrl2 1001 concttuctionto the N10%ft:
10.StaGt aatcrlevel bdntr top of easing: (tt:) Division orWater Reny rces Information processing unit,
1111.Stacie w snh.tne cnsing,roe 1617 Ma8 Senice Center,Rateigb.NC 27d"_l6t7
( l Ter e•i•_•etion WcLls: In addition to Sanding the form W the sildlaet in 24a
IL Dombotedinmetierr: ( U (in.) above.also submit one copy of this form within 30 days of COmpitstan Of well
e
11211+c1t rnnstrnettan method: pwnsttuttion to the following:
t i c.Mtge,story.Cable,('ir mt push,etc,)
Division of Water Rtattutt:es,Undcirgtvund igjeetioD Contra)Program,
PM WATER C+t PPt y WELLS ONLY.
Mail Service Center,Ratelgtt;NC 2709.1636
13a.Yield(OJtm) Method of test, 2,4c Dar Wter u Alft,&;oiecHon GYettt: in uddillon to sundirtg the form to
the nddress(cs) above,also submit and etipy of this fast within 30 days oF
tab.Disinfection t _ �motmr. complction of well eomunction to the c dm
owtt> health depaent of the county
type: whac constructed.
FWM CM.I North Cbmlmnt)epana.ont of tin-ird.meatnl Quality-I>ulmon oP Water Rasonrcas
RmriAed2-22 2016

Well Driller Self-Grout Certification
Owner: ('(AN ) AMN S New Well:
Addres- 19T wct 5� l ! air:
Permit:
I hereby certify that the above referenced well mras grouted m appearance in accordance with
A County Well rules.
Well DA im L m Ge-j®to-f Signed: --
Certificate#: ! Dare Grouted: �-�-�
Construction: Grout:
Total Depth: W05­ Type: 0-n
Casing Type: QV C Thiclmess: �
Casing Depth: UC) Depth:
Diameter: iblS
Weight/Thick
Height:
Drive Shoe:
GPM:
f