GW1-2022-00932_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwatet•Well Drilling 828-622-7241 P.1
WELL C011TM�,7CTION RECORD(GW-11 Par Internal Use Only:
1,Wc1 Conn•atlar information:
►es.i� ��1 1 -
14.WATERLUNES
iVcll Colinclor Name raovt Tn ntt s urrtoN
Well Cnnrtagor Certification Nttmler 19.OUTER CASING for motli•cssed wells OR LNEA(ifanftfte
Intom I M DIAt1 MR TUICKNESS MATERIAL
i ft, I n.
Company Namc (( ���^� 1� -16.WNEAt C DNG OR TURING thermal clored•too
2.Well Construction Permit#: 00WOt 1 + Os 1 a fqm." I TO IMMETER I TarcrcNEss MATERIAL
i.Lct all q/yiirnh/e well cnnrtrnalon fxrrmirr(i.e.rllr Cnnn/y,.Hole,Yrtrigncc,cu.J
EL (L. in.
3-WMI USe(check well use): it. ft. tn•
WiterSapply Wet: 17.SCRBSN
AgriCUlhlfal FROM TO DIA SLOTME THICKNESS MATMAL
unicipol/Puhlic Q ft, ft. in.
Geotherntai(Hcating(Coniing Supply) Residential Water Supply(single) ft. it. in.
[ndusirial/Commercial Residrntial Water Supply(shared) I&GROUT
Irti^allOn ^PRO O MATERM EMPLACEME!rTM DhA AUNT
Non-'*Vnttr Supply Well. t ft. 0
Monitoring Recovery ft. fr.
jectto Ad
lnn
Aquifer Rechar),c E3rroundwatcr Remcdiatinn ft• R.
19,SA NDlGiIAVI'sL PAC loanliable
:AquiferStorage and Recovery [3snlinity Barrier PROM TO MNT—M L 6M1-LACEMENTMLTttOn
AquitcrTeg ©StnrmwatcrDrainag: '~ ft.
Experimental Tec)malogy []Subsidence Control
Cicothermal(Closed Loop) [)Trace, 20.DRfLL1NG LOG fistinchadditional eessa fftettc.)
Creothcnnal(Hestia oolitKg Rarrrn) Qdter(explain under tY21 Rcmarfks) FROM TO DNtntarma,Wmkt rat"Ktap
ft. ft
4.Date Well(s)Completed:AA-m)—L Well IDY ft. -TOD
fL
S/u.well I.ncati n.. /� �1� ft. ft.
�.k�I Ol '
trilih:'flx ertlamc . aeility[DO(ifanplicahir.)
ft - fL
R, R.UL
AN
P sirnl Address,Cit ,and lapSECM ft R
2t. MARKS
It
County Paroel identification No.(PN) i
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sm
Sh.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Oweli rVeld,oonne�llatilog is anificinrt) !f '„2. a fitytti
6.]$(am)the wdl(s)�Permnnent or CI'emporpry :ittnature nECerttricd Well ator Dme
By nv Ming rlily;arm,I harry crrrlhr that 1hr twJl(..j awr fwerv)cYm rtuYed to octnrdnncr
7.is this it repair to an existing wet: :1-ees or No adrh LSA Al'AC 02( .OfOU ar 1SA N(.AC 01C.0200 Well C:rnrinrcnnn tilandoriLr emd Am n
/;'rhos is a rrpoie,P//mrlkngtvrr uvll.onarvrttnn ir{fgrmotion mrr rr/�Intn the noun•r!fiha tap y of flifr rrcrrrri Aw hem proi4de f to Jhe wCi/mmer.
rraoir under t111 remarks scrnnn rw na t/tc hack nffhis jnmr. 2;.Site diagram or additional well derails:
R.ror Gcoprohe/DPT or CJnsed-1 onp Geothermal WOU having the some 1'nu may use HIC back of this page to provide additional well site details or we►l
Mnsiniction,only i GW-1 is needed. indicate TOTAL.NUMBER oracils construction details. You may also attach additional pages if riocessary.
9-TAtat well dcptlt below land surface: 24a. For AH Wclis: Submit this form within 30 days of completion of'•yell
rr,rm,dunleW•ravimqvd.Pulridgar,„rrxapw,-rmmp'ond�+1i1001 consttuctionto the foltowing:
Ill,Static water level below top of casing:_ _ (R.) Division of Water Resources,Information Processing Unit,
1/'s»arfure,Isrrlvrvemving, 1617 Mall Service Center,t12stcigh,NC27649-1617
fi.Borehole diameter.- 1 V -�� (in.) 24b.For Inicerign Wct)s: lit addition to Sending the form to die address in 24a
12.Welt construction method- ��ll� above,also submit one copy of this form within 30 days of completion of well
(i c,AM %W faq.a*le,d irei,•t pitsk,ctc.)
construction to the following:
Division of Water Resources,Underground injection Control Program,
FOR WATER Rt,PPI Y WRLI„s ONLY: 1636 Mail Service Center•,Raleigh,14C 27699-1636
138.Yield(gptn) Method of test:bo Etc. Ger Wattr Sandy&fnlection Welts: In addition to sanding the form to
Me addresses) above, also submit one copy of this font within 30 days of
rib.Disinfection type: Amount: completion of%veil construction to the county health department of the county
where constructed.
Vnun GW I North Camlina IDepnntnent of tinvironmental gnality-Aivismn of Water fresourcac Revised 2-22-tat b