GW1-2022-00923_Well Construction - GW1_20220107

Feb 151905;43p ClearwaterWell Drilling 828-622-7241 P•1
WELL CONSTRUCTION RECOR1�{GW-11 For 1n(cmn1 Use Only:
I.WdI.Contrattor Information: I
14.WATER ONES
PROM Tn aescRu'rtoN
Well Coa mx Name In h ft.
NC Well Contractor Certification Numher D I is.OUTER CASING for mold-ased wells OR I.tlIER If a ieebte
To DIAMETER TI CKNISS Mug Y,L
Company Name 16.INNER CASING Oft TttBINC (berme(closed
2.Well Construction Permit#: iatox I TO I DGMETER I TBtCKNESs I MATERIAL
id all applicable we11 crtrxvtntctiott pa milx(i.c.J1/C.Cottitty,51ale,Yarla"Co,ctc.) Et. k. in.
3.NYclt llse(check well use):
Water Sapply Nell: -17.SCRBEty
FROM TO DIAME'rM 6tATS17.6 TNIcrsNtrss mATRIUAL
Agricultural 0Mtmicipaypublic U rt. ft. in
Geothermal(klcating(Contirtg Supply) E3Reqidenlial Water Supply(single) — h• h in.
indus{rial/Commercial DResidential Water Supply(shared) t&GRO
UT
PIRi^atlOn FROM TO M"IERIAL SMVLAACEM'/E. rM D&AMOUNT
.Yon.Yntcr Supply Vi'r.11: rt^ V R 1\ \�pc.�
�4onitoring Recavery
tnjeetinn Wcll:
ft. R.
Aquifu Recharge pGroundwaterRcmedistion 19 SAND/GitAVIsLPACK Ifo liable
:Aquifer Storage and Recovefy [)$nllnity Barrier (+ROM TU hfA lAL IIttrLACEMENTMCr1N)n
Aqu]ter Tcst 13Stnmtwater Drainage
uxticrimental Technology [35uhcidenct Control tr.
Geothermal((:lased Loop) Tracer 20.DRII.t 1NG LOG aaach Rildidaraldwis ifeacesstt
pRO34 30 DESC IION color. wWmrk f� rltNI
RiGI
RGcoLliermal(Hearin C�lin>;Rcntm) ]] Other(explain under R21 Rernarlrs} ^` tt. ft ,V/
4.(late Weil(s)Complete : ��-�"f Wclt
Sa Well)_nentlon:
U�Ci1�,�
Facilitys'(laner Hamc 6acility tDil( applicable fi' (L
iu
k &
ft R.
ysical Addrecs,Ci(111 � .,
tpnd ZIP
21.REMARKS
C.omttY ifa
l+atcel tdcmifeation No.(PIN)
5b.Latitude Find longitude in dcgreec/minutes/seconds or decimal degrees. -
ii we11 fie cS lbone latiloor is ski ident) b t +
2.Certif n:
3 ^ �— I -,E lio
_ t N1 (� �Y
6.Is(arc)the welt(s) Permanent or OTemporary Sian •ofCertifitxt Wel►Contmetor Date
Iry s tag runs.;trm•1 bombs c�cxiJy that rho turJf/aj xqr lwenJ rxmsrrunc+l to a.�hrAa!rcc
7.It this a repair to an existing wen: E)Ycs or No writ! LSA ACAC'OJ.C..I1lOU Fir 1SA XCAC d1C.',OI110 Well 9tnulardr dart that a
if dlJri..;�rcpatr.filloeudnnx•Fixcll.ronarnetianir;Tnrvna;iooant ripfairrthemniren('the t ynJOrferr'cur�lhaAhrt.'»prot9rktAJrithewr'i1nwl7er.
r:�mr tinder n21 remarkv a cuair or on ilie hark of!lily forni. 23.'Site diagram or additional well details:
R.Por Gmprohe(DPT or Closed-Loop Geothermal Wells having the saute )'on may use the back of this page to provide additions]well site details or wel)
m.nsirnetion,anly I GW-1 is needed. hidicate TOTAL NUMBER of wells cimstruction details. You may also attach additional pages if Docessary.
$UQMfTTAI.JNXRIIMONS
9-T41tal W911 depth below land Surface: o ( J 2Aa. 1 or Alt Wells: Submit this form within 30 days of completion of well
l%ar 1x+dliplc vrtly tier&Nd rptJu ifdr,$'erenr(exaniok-JCl//0'and 1 1001 construction to the following:
10.$tot)c warp level below tap of casing: O Or-) Division of Water Ramurees,Information Processing Unit,
//'xnh rlcrc!h'ahrlvt catfnR•tree"• 1617 Mail Service Center,Raleigh.NC 29699-1617
11.Borehole diometct: (in.j 2•11b.For IInlectiop Wcns: In addition to sending the form to We address in 24a
12.Welt construction method: chose,c submit one copy of this form 30 days of completion of well
-- const[constructionioinn m within m the following
(i c.mtge-,rnt:rrp.azbk,direct pusL,etc.1
MR WATER S+t:PPf Y WF.t.I 8 ONLY: Division of Water Resource%Underground Injection Contra]Program.
t636 Mail Service Centor,RjkW%b,NC 27694-1636
13a.Viet (gpm) 2- Method of test: it 24c, For Wglcr SanDly&Faiectlon Welts: In addition to sanding the forth to
the nddress(cs) above, also submit one copy of this form within 30 days of
13A.Disinfection type: Amount: completion of well construction to the cormty health department of the county
WhCfC C(itl.StrtlCtC'd.
Donn Gw-I North Cmv4inaDepnnment of limironmrrtsl Or,aliiv.iNvismn of Water Remarcac Revised 2-22-2016