GW1-2021-03799_Well Construction - GW1_20210823

828-622-7241 P•1
Feb 1519 05:43p Clearwater Well Drilling
WELL CONSTRUCTION CO "For Intemni Use only_
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Cmothermni(Kcatin oolinA Rcwm) Otber( lain under 97.1 Remarks)
d.DateA'ell(s)Completed:,.: 3 Zl Well il>t/ fr.
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C,unty Parcel ldcntifeation No.(PIN)
Sh.I,atitode and innpltade in degrces/milmtea/seconds or decimal drgrecs:
(ii well field,one tamang is suTiciient) :2 .;!2. ,e Mention:
Si Mere Of .crlifirdtNetlContrnetor �e
6.!s{are}Me welf(s) Pcrmnnent ar ©ITempnrary
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?.b this a repair to an existiag wen: 0Ycs or No +•itn 1sA VCAC 02r.0100 nr 15A NC•AC.OC.'.0200 Well Cnmfmcnnn StamlarA.t anti thou a
1"fid,is n mpoir,fill rn+rknewn uvll V1XV1fWWOn i>rfnrmafi0,r cord=plain rhr Panne n(,hc �oPl'of llrit rr.Mrr!has boo/lMsddi�f in 1hr wr11 nwtiu.
r"air rmdrr V(remnrkt swain nr mr Me hndk offhts fam,. 2.3.Bite diagram or ndditlottal well details:
R.Par Gm rone(pPF or Cla ed l.nn Geothermal Wells having+hc same you may use the bnek of this page to provide additional well site demils or well
p P COW tntclinn details. Yea may also attach additional pages if necessary
u�nslnrctinn,only I CW-1 is needed. indicate TOTAL.NUMBER ofA.xlrs
drillotl:__-_-� .__ _ y ranart-TAi tAi�+t'Ri1CTl<ONS
9.lrotat well depth below kind surface. ] J --(R•) 214 i6'or All Wells: Submit this',form within 30 da}s of cumItIc6on of well
r•rrMnlriprc., J&I;anlld:prh,f&fa,nr(rzomnlc-1@200'and2 100) cons)tttctionto the fdlowaitlg:
111 $tone waterlevel heinw top of easing: W.V (1't-) Division Dif ater Resoureea,Intnratatlon ProresmA Unit,
11'Mwericrrd isrktivecasing,rfu",` 1617 Man Service Center,Raleigh.T(C27499-1617
11-Rorcholediametcr: _C,n.) 24h.Far IaiectioRWdlse In addition to sending the form to the address in 24a
alcove,also submit one copy of this form within 30 days of completion of well
I Z Well construction method! a instruction to the following:
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Division afWater Reaottrre.4.Underground tt((tztlon Caattrol Program,
r(M WATPR 5CPP1.V WFLL.4 ONLY: 1636 Mail Service Canter,Ralciii NC 27699-1636
13a.Yield(gpm)_`U Vethad of test! 24c,liar Water Canoe►&iaieeHon Welts: In addition to sending the form to
Ibe nddrrss(cs) abotrey also submiL one copy of this form within 30 days of
t3a.Disinfection type: _ Amount: completion of+vdl construction to the county hWth denartmenl of the county
- whore conntnrcttd.
Fnnu C.W.I Nmh CAwlinn Deporimcnt of l:n.•imnmcnt.x1(:)uaaty-Aivismn oP Water Roeourer c Ravisal2 22-2a16