GW1-2022-00920_Well Construction - GW1_20220107

Feb 151905:43p Clearwater Well Drilling 828-622-7241 P•1
WELL CONSTRUCTION RECOR D{GW-ll For Internal Use Only;
1•WdLfatntrxctor information:
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— Os1!L t p� t WATE ZONES - -
TRON TO DESC Pi70.11
ivC i Contractor Name
r
V'Well Contractor Certification Nrrmt er ^^(� /� (�tt(rrr��� 1 qI&Ot1TER CASING ter maTtieated vrelh OR LiVFJt n e
1&t/J 11 1/ 1 1h 1 �'n pRDM M D1A IIOCH MA7EtttAL
U Win.
C.nmpnny Name IIL INNER CA9ING OR!LrMG Woftemal closed-facal
2.Well Construction Permit#: V W�MG imox 10 1 ou"L-ndtI Tnrcta+rrss NAtFN1AL
rice all ap/dia7ble wed ennrmretion pormita(I.e.1/1U rotary,State,6artanre,o.-) Ef. tG in.
3.Welt Ilse(check well Ilse):
Water Supply well: t7.$CRB-N
mom rO DIAMSTt9t sLOTSM THtc ttss trtAren
Agricultural Municipai/Pubtic () fr. ft. in
Geothermal(licating/Cooling Supply) dRLMdential Water Supply(single) n, fL in.
lndusirial)Commercial Residential Water Supply(shawl) a GROUT
[rrinotion hnoM TO MA1.6RML taVrMACetvlCVTxt`snf na 1110UNT
Non�1'nfcrSuppiyN'ell: fl. iL I
A4onitorin Recovery ft. ft.
Enjection well:
• fl. R.
Aquifer Recharge QGroundwatcr Remediatinn
-Aquifer Storage And Recovery E)s:tlhtity Barrier 1- COX
PACK MBT t L)e t►tACEMBnTML7)cC+t1
Aquifer Test Dwrtnwater Drainage 0.
Lxperimental Technology E)Subsidence Control !L Et.
Geothermal(Closed Loop) [3Traccr 20.PRIIJA 4G LOG toMach addidavaltherts f
FROx TO rr eator. rdoem roWrock rake r�etW ,
Geothermal(Hearin Doling Rearm) Other(explain under 01 Remarks)
-4,date Well(s)Completed• Dn We1t ID# � ft,
W�1 1.ncnHnn: ft. R
\t cb� it. n.
, r-
I acilih:'ik+rM liamc �acilily iM(tfapp'able) QEL
�SQ,4 c- r R. ft. 7
P sicnI Address,Ciry,an p `\� n. R r w
21.REMARKS
County Parcel identification No.(P1N!
Sb.Latitude and longitude in degreesiminntes/secondsordcc(mai degrees:
0"'.%V 11 f�(jne 1atno na is srliricirnt) � �V
6.ls(arc)the wells) ermnnent or ©Trmporacy Sipnar c of Ceniried Well Contractor Date
11v genial•rhlr.;rem,)hrnrhv really that the aa!/(a)xwr(werr)crxvrrmmd M amwdance
7.I.s this a repair to an existing well: OVes orZNn w tr!SA.Yf..'AC o2C..010U nr!SA NCAC A2r.'.r1:00 Wal!(:..rraln+rrimr SlomhrA.e meet rhm a
,r'fbir is;,repair.fill nruAnrotvn nvdl eonarr+ctinn infnrrwrtan arc rxplr>in 1i,e.mwt,,.r grthu eopv nfdrla rere rd her been proMat to the wall om r.
r raw nerd r 4:1 remarkc.rcritntr ar ern Un:Mrck aftllh.(nrni. 23-Site diagram or additional well deMits:
A.For GeoprobeMPT or Cursed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well silo details ar well
oenslumlion,only I GW-1 is needed. fruticato TOTAL NUMBER ar ells construction lictaiis. You may also attach additional pages ifneeessary.
drilled: 1 A iNti U NS
�� r���l�...l` STD.-.s�12
9,'Total well depth below land surface: _(R•1 2,1n, IF
or Ali yVellc: Submit this form within 30 days of completion of well
t"rrrauhip/c sat/s IiV rrlietpnrr ifdljjonrnr faramo�e-an�nn•a,,rd;@loot cnns(r or Alctian to the 1s:fol Sing:
wvlerttc Water level below tap of casing: �0 (ft.) Division of Water Resources,Information Processing Unit,
1 calm•leer/a ahnca casing,rru"••' t l (r 16171Mail Service Center,Raleigh.NC 276"-1617
TL t4onehoic dlnmetcr: t+ (in.) 24h.For intectign W ls: in addition to sending the form to die addrea in 24n
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
(i a mr ,•c,rotary, construction to the following:
b• ray eabk,direst ixtsh,e:tc.)
FOR WATER SUPPLY WF.t.LS ONLY: Division of water Resource%Underground injection Contra)Program.
1636 Mail Service Center,Ralcig6,NC 27i;W1636
13a.Yield(gpm) b{ethod of test: 24c.Uar Water SuLgy;&iniceflon Wells: in addition to vending the form to
the nddress(es) above, also submit';onc copy of this form within 30 days of
13h.Disinfection type: Amount. completion of well construction to the county health department of the county
where con tmcted.
Ponn Gib'-I Nonh Carolina Depnnment of tin.ironmcrtal Qaatily-nivistan of water Rmourcas Revisa42-22d016