GW1-2021-03804_Well Construction - GW1_20210823

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Fc-b 1519 05,43p Clearwater Well Drtllin9 �, •'"""
WELL CON.STRIJCTit011 RECO)i�A{' lil Fnr]nlemnF U9e nty:
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tUrii r'mltrautx Nnmr n to n• ____
:VC Well Cantnryno,C�ratiflaMtonith,mter C R fit,
t:n npnny Nnmr. ii, R o A61 L —'—
?..Well C.onetrnetrna Rermit>g: M07Pid la n M rmMicrtttr,Daftrmttlmetlnn m :fnnrNy,Shrl�,YQrlm+ac,�t.;.l
3.NMI Pir_teheelt well un): �
4Ya Icr Supply w(i.
Agrtcultural unicipaypubac tt, % ft
Geommlal(kieering/Cooling Supply) esidential WawSnpphl(single) t?i. in.
IndusidellCommeraiel Ritftesidenftl WalevSupply(ahnred)
rrti ration nr ft.
Non-VISi>er Suppty Wejl:
Mat►itoti ©Recovery �^
fnjceilan d: ill.
Agaifet•Rechetpc r3CroundwaterRemedWinn 1a VRLPp le _
tarntou
AgW&r Storage end its overy E3&dinity 13AWCr
Aquifer Tcst [3Smnnweter Dratnet:g A
13xpccimcmlel Tcetnrafttgp �Subsidenc+:Cotttml
IL - R.
cicotheirtal(Clawed LOOP)
f eothcnnel(Hceftng/CRotintt tLcntm} C31her(explain undo ii21 Rcmetlts .A— ft. ra r• Y
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d.Ratr.{,Ve11(a)Cttrttplrtpd;�/ Wniyl�iD#,.,.,_,___---• _
AA!4 -Well l.nrnnons (.�'�S T 1� eei ft.
f a4ilitt:'(Itvr,cr FAOlitylDi!(rftgrpliaxbla) B"
Foi-
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�itysicol Adolrots,City,and lip N
2. AR
C aunty ('areal rdertitientic,n Nn.(KN) rt�4
rt�^
!Sit.t.gtilndr omi lonAltude.in degrm/mimit0fiec0ads or dcchltel drgr¢es:
(it'.vpll fia�f,ono fnManK in e,dliaienf} is / ('e tQcaiion:
4.ts(arr.)the well(xj t+ermanrnt or �i elrt(tnrAry ,i rmre tei tkritfiadwdl Cim4nator a
r;j,:apnroR ru>fi•pro.I hr"yf mrlfp that thr,twdt(gi M=fNwvf croon im in nemro'"re
?.t;,this a repair to an existing tveiC Xca or ONO t to Nl ACOX.'I11e0 WanCotlrrmainlrSYprrrtgrAt oml ohm a
/:rhre I.—rapntr.fill trurintaem 7ratr aonaln,et/pis hi/nrma/lartmrr rain 11"!rxmm•c!fohe anise PM111Wlothe NMf!Mww.
r.'Wir elralrr,A)/-ma*stain fir ovAir.har.ofthtr fnrar. 731,Bite g$ram or a0dHIMM spell dda tt
R_Ffir Cimprohe/ApT or Clued-lamp Ceothertnnl Wells hiving she s me Pou ntap use the tsttelc of this PeBe to provide addltionn)wdli she dOWIS ee•—11
t—IT-finn,only r Cr kw is needed. rndicoct TOTAL NUMBER oruclic rongtruciion tirtaits. You may AIM itftfth additional 11290If 110"fry.
drilied:___._, _
i
9.
Tntar well ttepfAUoimvLtndsurlhee tR1 W. Bar AR wr�1a: Submit fi►la tlitm tvi0tin 3Q dam of t�rnMiletion of wcli
tnrnorrrapier•wile/itrr.11Aepr7ui fwaram(arampin^4R+V �t��fIRR7 ronAlmionto the fallowice•
Itl.Simi-•tvatur ICV41 bt:toty top of rnsingt_ _ (R.} Divisloo of Watter Reamrea%tathraitNian Precersft Valf,
ffatrrerlumxf is#N P&w.",vee~•l" 11.17 Matt Service Center,Raleigh.N(C 27M-1617
r;_Ronehnieeittmeter; pis.? 1.4R.For U�wdF to addition to fading the farm i4 the MOM if!248
�n ,� 0 ldtnvq Mw Submit one copy of this from within 30 da3m of reamplftlon oP wdl
12^Wen eonitruetion nidbud: �s��..s- rsnttstmcClon m the follnvAgg:
tie,mify:•,mtntp.a'tMe,direst pttalt,ctc.l _
rYfR WATER St:PpL WE1,r.8 ONLY: Illutsion Of Water it Se rt Ogb Apmrund'er$fRmtdgL,TIC:069•^16MIS PitlRt7lm.
�j IG3ti Maf134vICe cnntinr,
13a.Ytrtd(RPtn)6_ MrUroU of fe4h ._ 9.ic Rnr wetrr Rutrely&ieloeflon ytrelrf: in addition to sanding The than to
file mddmess(cs) above, also submit ahc copy of d* form tM19 30 doylt of
rah.pisinfection type. Amount completion of W41 Plow notion to tlfG cmMly knitll diglerfl M orihc amlify
where onnstraew.
I+inn Ow_t
Narih l�tmirna f)apnrtmone.thin.irnnmantnt Qmellty^tNvis,an of Water Rnyantcex lfeet�etl2�2-7Ri 6
i

Well Driller Self-Grout Certification
krfu,C`iCAS v�"\`c-
Owner: �tmber\l.l V,..4e, New Well:
Address: )Q q S Sa-t1�.� C� Repair:
I?exmit:
I hereby certify that the above referenced well was grouted in appearance in accordance with
all County Well rules.
Well Driller: Nox-1(- A t�zn Signed:
Certificate#: Date Grouted: L 1 '-41
Construction: Grout
Total Depth- Type:
Casing Type: Thickness: e4 CA
Casing Depth: Depth:
Diameter:
Weight/Mck
Height:
Drive Shoe:
GPM: