GW1-2021-03761_Well Construction - GW1_20210823

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Feb 1519 05,43p Clearwater Well Drilling
WE�s,tr.`�QNS�'RUCTEON RECEIR�r For lntafnai Uac nly.
I WA.E IcA a Information: -Alma tar
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2.Well Comitrnetina Permit#: f1 R In.
i.irrnit nrppcnhla,ocNranrrnrcilnn pernt0r p v.Fyir:C-mmy.Ma/4 Varlanca,st:.l
3.1Yr11119r.(Check well tlsr) tZ B8B fAL
We ter supply Weil: 7t►
Agricultural Mttnicipnlfpuhiic
Crrothermal(1-leatinglConling Supply) Residential Water Supply(single) ri
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Indusirial/Commercial Residential WAletSupply(9hare'd) " L QiPI
T au sNtru cn7at & trtir
irrt Delon S1 f1
Non Wnter:iuppiyWrit. V
R4oairarinInizecovery ft^
(njcetirrn Well:
Aquifer1tecba%c [3GroundwaterRemediatinn "" aNil/GRAtr6LP
Aquifer Storge:and Recovery E)Snlinity Battier (L
tau art riton
Aquitcr Tev DStarmwi ncr Drainage (L
Experimental Technology 05ultsittcncc Control
ft tt.
Geothermal(ClosedLoop) 137raccr 20. >11LIL tYs taihee;& Inc.(isothermal(HaRting&aolittt;Return) �(7lti EkEplain tmderfl21 Remarks) tt, To Cc ft. _
4, (.e-o dj Wel(llm /l�/7 ft. 7
Matt well(s)Completed. — ,t-•--= Q,�+�ta,;o -
Su.Well l,nrrinnn: yAA U id OlcmpY 'f
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l acilitv'f wnerNamc faerlity tDil(if applichhlr.)
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Mysi—I Addme q,Ciry,and Zip
fi/j i,,,j t�� � � 2t REiMARKS
C,naty Parcel ldratiScation Na.(PN)
51t.Latitude oral longitude in degieWminute>;/seconds or decimal degrees:
610-01 field,one h0aW in sidricicni) p i n cation:
17
C Nam)the wells 4PImonent or Dremporary ifinainrc of Mttfiid Weu Cmnrnamr Onto,Rp.dl(ainjg thts•�,rm,I hMwhv rmttfy trrol fhr,IWAtV Maf 6�nrI cwsyntg"'n oavurfa7re
i.In this it repair to an eidsf(ng well: �Ves or �I4a ndtir i.SA V1.AC 02Cr.0100 nr 15A NCAC 62C.'.02M Prey!Cr.»hair-VwWardc and char o
Ohl"ix e>repair,fillmuknown ioefl,mawnrclran h0—lian OUI Rpraiir the nnnrrr r?riho nAY of lhLr Ravrrd pachPBl prO►adart la the Wrll mvlier.
r•,:pnir rmdcr 01 remake gr:caan arem tlm hark aflhlx farm. 23.-&1 diagram or ndditlDnol wan dialla:
R.f'nr GCaprahell)PT or Closed-ll Geotbarmnl Wells having the same l'ou*naY use the bade of this page to provide adds mRl wall Bhe dosib or weal
wmslnirtian,onh I GVJ-1 is needed. fndicmat TOTAL NUMBER of-rlis cAnstnrctitat(tttails. You may also ltltach addi(ioml pagl;S If noees9erv,.
drilied:—..- -- (' 15UNlt't'ULiN U,B,,.Cl'M
9,Total welt dkpth below land surface J __(R:) MR.}tor d,(1 WAh: Submit dlia tbmt-tvl(hin 30 doses of companion of well
I'nrmnN/1dr.—I?C Hit UdOpfieffAlperrtnt(example-304100j•mtd'n1001 cnngtriMiatl10 the f0110lTIM
10.StO tic water level below top of casing: `-� 0 (it.) Division of Water Restrurcea.lnformation Procasing Un)f,
l�'nvricrlrnr.Jh'Mvri+cartlrrAtrre"•" j 161711'IaflSarvlcaCmter,Wldgh,]i1C:19k19-t619
ti_Ror+eholeAiametcr: a4b,FM t�s_In,_,ctiaa HWIF in addition to sending the form t4 the addfws in 248
rD t idroM also submit one copy of this form tvilhin 30 days of camPWan of well
17-Welt construeNon method-_ _ ^, aonsitacdon m the foilowing:
(i c.mrne•,meaty,arblc,directRush,qcd
Division ofWater Rtscurrecr Underground injection CORMW PnVMM,
JrOR WATER 81:M V WFLL.R/ r ONLY: I636 Mail Setvlire Cenrf,Ratelill NC 7.7k�5•1636
F
1311.Yicid(gpm) / J Meow of teat.„ P.4c.For%'Ater Surlily&is Han Wel In addi(ion to sending the lbrm to
ilic nddress(es) above; also submit one;copy of this form within 30 days of
r.tn.ntxinfecnon type: F Amarmr._� / comptetinn os�v+91 rnnsunetion do the connly haldlh depattm n,I,Inc GmInty
vrimo a amstmeed.
�'^""f:'tv-t hearth C.rrmlinnm�apnnmont of tinviMrtmmenl Qrmthy-i�iviarrn,or Water Rogonrcee Itevisa!2 22-2M R

Well Driller Self-Grout Certification
Owner: New Well:
Address:}-�Gc.1k Woad ��: �CLrS� &pair:
NC
Permit:
I hereby certify that the above referenced wa was gmuMd in appearance in accordance with
all County Well ivies. ?,
Well ller:�Pi �lFt t�,e� S Sipped:
Dri
Certificate#: -:D l\3- Date Grouted: U
Construction: Grout
Total Depth: Type; cafYA?y_�
Casing lMx: MC, TMclmess: tin i Vk G
Casing Depth: 20
Diameter: �¢
Weight/Thick:
Height
Drive Shoe:
GPAt: `�