GW1-2021-04142_Well Construction - GW1_20210823

------- ------ ----- 828-622 7241 p,1
Feb 1519 05:43p Clearwater well Drilling
WELLCQNSUM TION)<2EC For in(emal Use Only:
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2.Well Construction Permit 9: N. k In.
i.i.rt aN opliftwhie wall canrrnrdlon parmar tl.a lJl(T,Gnan/y,Sml`e,vartmx.e,d:.) B• in.
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3.Well 115c(check well list): 17.SCR6 N �atcwv ssnun.
Water Supply Well: I To n AnfRrER sum
Agricultural
unicipal/puhlic () R n'
lv evidential Water Supple(single) R, ft. fir.
Gcanerma](I•Icating/Cooling Supp,)
CnduslriallCommercial Residential Water Supply(shared) ig, OUT To 1117<RtAt BAtM.A � �1T 31ETNOD di AA7onitr
[rriaotion r+, R- 0
Non%Vnter Supply Well: fu
Monitoring r1lRecovery lt.
injection Well: ft. R-
Agnifa Rechar&c �Croundwatcr Rcmcdiatinn F 1RAyBI PA a ills �� g MCt7tOn
aquif�v Storage and Recovery E3S:dinity Ranier +t- n. Iwr+ L
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Aquifer Test [3Sw mwatcrDrainage tr.
Experimental Technology
5uhsidence Control h
20.ORII.T.INGLOG attae6D ppheekt �t
Geothermal(Closed Loop) DT(- FROM TO
Geothermal(lieatin oolir//rA��Rctsrntl dater ex lain udder A21 Remarks) to R '�
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a.Hate'Wetgs)Completed: Well IDfi_ __________
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Physical Address,City,and Zip '
2l.REMARKS c��•'
C111I311y t Parcel idemifleation No.(PTNI
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Sb.Uttitude and lonp,Itude in dcgrees/minates/secondsordccimal degrees: - t'
( ell field,ane i80angis sufficient} p 1 2 t'.ftlf�lrion:
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t�l em ore Si@nmurc orcrnucc t well Cmranctor
�.is{arc}the wells) Ptxmanent or l.�tll p rY crma�raaurl'a aCnaMan[e
by all sing I/r1S_i'u7».I lrelrhl v errrth'flint tilt.nYal()scot fWQn j
7.in this a repair m an esdsdug rvdL �Xes or No wf1h 1SA tiCA[.D7.f..1110o�+15A VCAC 01C'.p1(10 tYrll Cunrlrnerian SYnudarrlr Mrr!'hm n
!,+'tbfr is:r repair.fed nrrt►arnaw nv!Il aoarin+ctfan irlfnrmotina ant7crptaM file rxrnur t(tile copy oflhlr rrdord NorhM. prrrv/d'ig.rrn rile well mm'7-
rcpoir Hader 1:?l rclanikti SCrtl(N+nrmrr/m hard of tots jom+• 23_Site diagram or addMorml trill detaltst
1'ou may use the back of this page to provide additional well site details or well
R-Fnr Genprahe/DPT or Closed-lw+np Geothermal Willa having the same construelion details. you may also Mach additional pages if noeessan+.
consln+ction,only I G%F.I is needed. fndimto TOTAL NUMBER of wt:llc
` rnnaarr-rst 1tr.STRUf'1'[ONS
9,Tat-it well depM below land sltrfacc: ` �� —A) 21a. B r Al VI: Submit this form within 30 dabs of completion cif will
For aii11uptr w e I I r Iitr a,dcprla ifdf,.at(rtNnplc-.i itiaYanr12 @Ia01 construction to the following:
I11.Stetie water level below top of casing: (ft.) Division of Water Raneurees,Information Processing UOR,
ljsvjlerI'aw!h•rrlowe(mving,axe '• 1617Mlit Serowe Center,Ratetg NC276"-1617
I L Ttorl hole diameter- k V (in.) 24b•br iniertinn WAI in addition to sending the form to the nddrem in 24A
above,also submit one copy of this form within 30 days of completion of well
14 W ell constnletion method: cnttstruction to the following:
(i c.auacz%mtaq.cable,direst push,do
Division ofV1'ater Rtntlut'aes.Underground Injection Control Program,
r(M WATER SUPPL V WELL q ONLY: 1636 Mail Service Center,RAlcigh,TIC 276994636
130.Yield(gem) Method of test• 24¢-For Water gotfoT:;&I Igagin Welts: In addition to sanding the fats to
I the address(cs) above. also submit one copy of this fort within 30 days of
13h.131sinfecnon type: —__ Amount: completion of well consunetion to the county health deparnatat of the county
where Cnn9tmCted.
I nos Ctt4-I North CnmlinnrJepnrtmentof Finvlrtinmrntnl puatity.Division of Wahl ttesoarcec Reviseil2-22-2016

i
Well Driller Self-Grout Certification
owner M6 &6,Qf C°° New Well: V
Address: AS �v �r Cr4.& L ,Repair:
Permit: GUrnS\AkV_ Ls C
CM
I hereby certify that the above referenced well was grouted m appearance m acoordanae with
all County Well rules.
Well Daer: ��d o Signed:
Certificate#: l e Date Grouted: �k_7--I 1
Construction: Grout
Total Depth: Q S_ Type:
Casing Type: fW C. ThiclmM.
Casing Depth: 7 Depth:
Diameter: CCU 49
Weight/Mck
Height:
Drive Shoe:
GPM: t