GW1-2021-04045_Well Construction - GW1_20210823

Feb 1519 05.43p Clearwater Well Drilling 828-622-7241 P'1
M%JE L Co NgMIICTION RECORP f IGW-11 i7 sit'Intern#Use Only:
1.Wcl ntraemr Information: _
(� lg, LONE6
}� ®'U m_�_ Ta nos nitrt
'Veil
jColl"Cloth(a�me
?1C W41 CantmourCcttiRcntion Number ��pj R SIN!+ t�111n1 a
MATERIAL
UMrW w � rJr; t pIRDM t,. � f,. tt�to I/ t
Campnny Nnma �6.r1Yff1"sR CASING QL;7'1rt;ING tbotmal e
2.1Yell Construelion Permit#: R054 f,. TO h DUUMC>R t MATMUL
UN,all alyr(lcahfe we11 Cortrtn etioninimax(La UIC.CnnrNy.BYoJe V4Wanca,err:)
3.WeR 119c(check well size):
WaterSupp(y eil: 1 ro etvT Tp► � reaaL
Agricultural QMonicipoUPuhlic () 1r ft.
Geothermal(L•leatittg(Coaring supply) ,Residential Water Supply(single) f,. is
Gtdusttiai/Commeta)al QResidmitttl Water Supply(shwvd) 18 t O1Pf -
_FROM _TO MA L rLAC®M6'ft' Adr.AMatllrr
ltli alian
iVnn-N nfer Supply N rtl:
A4anitaring QRecovety
Injection Well: — n- R
Aquifer Reebatge QGroundwatcr Rcmcdiatiim J9 A )y L PACK Ea
Aquifer Storage and Recovery Qsalinity Barrier leolt Ta ln►trwertlae bttertton
Aquifr Tcst QStllrntwotcr Dra)Rtigcl n
R- R'
• flrperimenlat Technology QSultsidencc Control
Geothermal(Closed Lone) QTraoet - RILU1NC LOG m1ar. ratwdwetc t
Geotttcnnnl Hcotin 1' R,=ra) E30th.r ex tan+tmdcr#21 Rcmiuics) pt3otrt
A.tlafeA'efl(ra)C.Mopleted:�a Cs ' well I1N1 7® � -
'in Wyei�l I.nrAtirtn: n • �r.s
l acilihtr(ltwrer#Isnnc Facility Dy(ri'mPlicAble)
ad r7 9 Q� f TM f
Phvsicni Addren,City,And"7'� fL
J'
l9-� � �
County PnMel ldamifrratitnt No.(PIN)
51).Latitude and longltalle in degrees(minntes(seconds ov dccimnl degrees:
(ii will field,one tedlong in suillefent) o Y !! '2•Certlfiattion:
agrro„rEof(Mir dWellContractor Date
6.ls(arc)the well(s) Permaaent or ©Temportlry /
c f..N utmmg rhlr farm.I herwhv,•mrlfy Act the own(s)""s(bare)rortarrvmd In ar—d-re
7.in fills A repair to An Cld➢flap,well' or �IVo v tar 1SA ti!_'Ad ox-#flit)or 15A NC.AC o1C.•.021N1 Wr1l Cnmlrnctfna SrotodordR mid thm err
�rfhleis n rytolr fi11 mrrkrtawn tu.t11 uonurncrrnn i>jfirrmmlunmrrnri/rlairr!be rrmvn..J)hu r/iRU nflltlr record hoe nrMtl prbVffJ!!d rnrl�tVCf(AW77tJ.
n;rair ender t,21 rcotatire srcrdan army the hod-r jthis fiam. Zg_Site dWRrarn or additional Well detalls:
8.for Geoprobe(DFT or Clot A4.onp Geotbermai Wells having the same You may use the back of dlis�$e to pmvide additional we(1 site diy. to well
c insinretion,tmly I GW.1 is needed. 11ndieate TOTAL NUMBERof-wclls uyr►twcii0n dettnls. You may also attach addit'tontil pages 1f ilIM teary
drilledt____-_ n AI R If'i101Vfi
9,;rota!Weil depth below land SurAcct r �� (R•) 2,11a. I>;'er Ag w_elis: Submit Stis fmm;within 30 days of completion of well
r�arnan(uplcwrNsliseraildeprMrifd�'ercat{euwph-9(n_1J00'mrds�i ltiQ') cnnstruciiantntltcfo)lol�ing:
10.&u&c water level below top of casing:. -- 00 Division of Water Retourees.Information Processing Ilrtlt,
l f x er(avel is fAmr wring,ute •"l 1617 Mad Sbrvke Center,Raleigh.NC 276"_1617
ti.Boreholedinmeter: ° _(in.) 2Ub.For Iwicrlion tYad)sa To addition to sending the fort to the addinss in 24n
rnq , f atmve,also submit one copy of this form within 30 days of c=Pldlotr of well
12.Weill constroetlon metbod: Y V' ® ' ram9nm ion to the following
(i c.anger,mtttq.eable,direct push,dc,)
Division ofWeter Reaourcesr Underground Injection Contra)Program.
f1012 WATER SL,'PPLV WELLS ONLY: �— 1636 Man S"ce Centcr,RAleigh.NC 276994636
i
13a.Yield(gpm) / Method of test: 24r.,I?or Watar Suppl�iaieetion,Wells: In addition to sund ng the form to
the addrcss(es) above, also subunit.one copy of this form within 30 days of
tab.Disinfection type: _ — rlruoumh completion of\veil consuoction to the county health department of the county
what constructed.
Fmnt Gw-t Nortlt CtiunlimtDcpnArnont of tinvlrrinmuntnl Qrmlity.Division of Water Ra"lumac Revlved2 22 2016