GW1-2022-00986_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 p'1
WELL CON§DVCTION RECORD(GW-a) I
For lntemn[Use Only:
1.5'!rC)LC'.ontrattor information: c
._-.L_l_S Jos l_.L_ v mWATEIRZONES _.
rttoN TD D wrhtoN
Well Can1oragvt Name n- fb
N' ell Cantrallor Certification Nlnnber s.OMER C RING for mold--and webs OR UNER ifa livable
n4neoM M DtAMCBLR tantess MATERIAL
tt. ( ft. in, wc
C.mmpany Namc _
1
16.INNER CASING OR TIrRIN4 tharmol deed
2.Well Construction Permit#: PROM I TO I 014 t rE THICkINIM w+t>`RUL
idrrn110MJi(V7h/e well o,,XTJr11Cf1o11 perMitr ffa UIC.Canrxy,Stoic,trarlimce,ctr.) ft, k. in.
t -
3-lydl Ilse(check tvd)use): R, tr. in.
warel-sapplywcn:
FROM to DIAMETM I SLOTSME 'MI KN6S5 I MAT61CtA1.
Agricultural Municipal/Public 0 tr. ft. in.
Gmhalnsi(19eating(Cooling Supply) esidential Water Supply(single) O, tt in.
Industrial/Commercial �ResidcntialWaterSnpplp(shelcd) MGRO1I1
[tTi^ali6n FROM TO MATERIAL 04PIACEMCNtxnTHOD&AMOUNT'
Non-Wnrer Supply WPM: ft. z O R.
[q.i
ng Recovery to. fr.
ell: -
Recharge �(ironndwatcr Rcmcdiatinn n. D.
19,SANDIGRAYEL PhCK [ litsWc
Storage and Recovery Salinity Barrier FROM TtTM1tA lAL FMPtwCEMEnIVIETUOD
Tcst Q.StorinwaterDrainagcttt'•ental Technology 13Suttcidence ControlIt. n•al(Closed Limp) [3Traccr 20.DMILL1 LOC sttschad ehaets fnaI(Hcatin orotingReLurn) (hhrr(explain tntder#21 Rcrilnrl:s rRRovt To DESCR1rr10N mbr,luraam,roWroc4t . raMeiwete.
t tt. 17) tL
a_Date Well(s)Completed: well IDst rr, L Ira-\[r
Sa.Well Location: W flCd S t'' f We
c n. S n. r
" `2 .
F-TilihIM-AlIcr Marne n. rz Q L 2. 3lE"y t is Ir.)
ft R `
Physical Address,City,and Zip
21.REMARK$ I t r
CauiuY Parcel f lemification No.(PTN) —CIA ly ip
5h.Latitude nod longitude in degrees/urinates/seconds or decimal degrees:
O wail rreld,one latliong in nufrieicrt) „rZ.Certifir 5EU I iQ 1
• 11,i(v1=oih;I'i ' 'r' .,urn
6.Is(arc)the well Permanent or ©ITemporary Sign c ol'Certirrot WellContrnaor Date
sliming tbtr turn+,1/rerwFvrxrriii:that Ar%*.W.)was(wera)armoraitkiUrVewrdonce
i.is this A repair to an existing well: Oyes or�No bb 1SA a'C:'al.'n2t .91no nr 15A,YCAC 02C.0200 Well Cunr/rr+cnrnr Srondardc Mid ohm a
1'Od is 0 mpoir.fill(n+rknoKm w,ll eoarrruclow i>(formalion and replan The nrnrrre r flhc lnptt of lift resv,rd baf heat prorid*f tot&well mwter.
rz tole nndet+1 t ramnrkr.rcrnnn menu I/m hook njthh'jarm. 23.Site diagram or additional well details:
R.For Genprohe/'11PT or Cloned-Loup Geothermal Wells having the same Vim may use the back.of this page to provide addit[omtl well site details or Weil
w-nslntctinn,only i GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessery.
drilled-,�__..�_ �.. 1 fiTAI. R7�LICTiONS
C('�
9, "'Al3' well depth below land surface: J�� ,(R.► y,i t, For Ali WOW Subunit this form within 30 days of completitm of tvell
1%rrronl+iplcxrll.elites/rd.rUrri/d.$arcnrleum+ply-3CIB0'and inOq consirlictiontothefollo►ving:
10.Static water tevcl below top of easing: _ ((t.) Division of Water Resoureea,information Processing Unit,
V*%,aterfuwd is,Airsvm,inR,rt+e''• 'l1 lblTtiLflScrvlccGeDter,Ro[Ggb,NCx7h98-1617
t i_1lorcbole diameter: (in.) ]db For taiection Wells: In addition to sending the form to the addres:t in 24a
12:Welt construction method: above,also submit one copy of this form within 30 days of completionof well
(i c,au},•er,mhry.catch,diralti push.etc,)
construction to the following:
EVirl
SI:PM Y WELLS ONLY: Division ofWater Rrsources.Underground injection Contra)Program,
1636 Mail Service Center,RalelO,NC 27609-1636
ln) Method of test: �� lie.Eor Witter Supply&iniccHon W0111. In addition to sunding the form to
the addresses) above. also submit one copy of ibis form within 30 days of
on type: Amount: eamptetion of well construction to the county health department of the county
vrttcre constructed.
Fora C'W-i Noah Cairlina rtpmnment of 4+rawly-Div+s+mo of Water nosmucec Revised 2-22-2a1 b