GW1-2022-01014_Well Construction - GW1_20220107

Feb 151905:43p Clearwater Well Drilling 828-622-7241 p'1
WELL CON§TRUCTION RECORD(GW-1) For]n(cmal Use Only:
1. cllContractorinformation: I
_hCk_MeACbAa5 14.WATER ZONES
We�ll,ConwauorNaint rROM i To Dt:s wt�ttox
�•"--'�� ' `_...r.....�..._� to ._. ft.
�NC Well enntmCipt Cort�tifio�Atio/yn�Nmnher \�x^'`\ is.01ITF.R CASING for malli-twed wells OR LINER if a liceble
_r!aL`•'^^ .-. I ✓1 ' I�I n PROM 70 DtA 'fll[LXn S MATERIAL
it, f6 // in.
C.nmpnny Name I _
16.INNER CASING OR TUBING fawthowlsial closed-too
2.Well Construction Permit 4: "irROM To DIAMETER I THICKNESS I MATERIAL
i.i.rt all nppJicande+vc11 canunculan permit,(1.e.II1C.C.nunry,Sca1c,lrarrnne•c,ck.} R• N. �•
3.IYe:111fic(chetk well use): ft. tr.
Wo ter Supply Well: 17.SCREEN
FROM M DIAMRTI9i. St479�.6 THICKNESS MATBRfAL
Agricultural Municipal/public 0 �• ft.
Geothcrtttal(FicatiuglConling Supply) Residential Water Supply(single) -M ft. in.
[ndusiriallCommercial Residential Water Supph;(shared) 1&CRolff
1M�a[i0n FROM T ATE IAL EMPLACWE.`tTMs ODat:AMOt1NT
iVnn-'*1'altr Supply Well:
fr. ft r
Monitoring Recovery ft. ft.
inaeetion Well:
f1. R.
Aquifer Reebatge Q(iroundwator Rcmcdialian 19 SANn/CRAVEL PACK a fable
.Aquifer Storage and Recovers' Salinity Barrier yPROM TO I MATt7t1 L fl1trIACEMB(tT MCTiiOn
AquiferTcst nitnnnwaterDrainage °- ff.
Experimental Technology Subsidence Control rL it.
Geothermal(Closed Loop) DTCUCF 20.I1111.1, CLOG altachoddhionslsheetsifnewsa
FROYT TO Cieothennal(Hcatio soling R.clurn) II Uther(expluin under f121 Rem DESCRIPTIONcobr, rAWk traw, Out etc.)
arks? te. re. SM
.4.Date Well(q)Completed.��{Well IDfi ft. (t,
Su Well I acatlon: D ft !1 I,.
--
F lily"O%Aarcr)lame Facility 041(if plkahle)
' Ed ft. fr
PhWical Addres,City,andA rp
.21.ItEMARKS
County J•�._ Parcel fdcmification No./pihl)
5b.Latitude nod longitude in degreesiminnles/seconds or decimal degrees: +
(ii,well ficld,one tattiong is suffici i p "2, a re lion:
6.ls(arc)the well(s) Permaneat or ©iTemporary $ignniure of Certified Well Contractor Date
TTTTT ,�/� ltv.et}minh r11rs.fi rm,1 hewl.vrrrYljy rhal 1hr twdf(x)mrr(were)crmnrorrud in accordance
i.Is this A repair to Rn existing wcJt: oves or tNa w'Ih JSA.Ft:'RC.'02C..0100 or 1JA YCAC 117C.0.00 wellConsUrrnioe 590ndordr imd chin a
;�Ihir is:>repair,fill rnrtknaam will annsrrncdinn infnrmalirrn r rpinin rhr.nnaer,e r(chu enplr nflkS trrwonl har herd prodded to 11w well nww-r.
repair und:l G;f rcmarlts scr/Mrr ar rhr lln:lvtrl•of fats torn,.
23.Site diagram or additional well details:
8.Por Geoprohe/DPT or Closed-l-arip Geothermal Welts having the same 1'ou may use the back of this page to provide additional well site de:mils or well
mnsiniction,only I CT%A.1 is needed. lodicate TOTAL NUMBi:R orwclls construction details. You may also attach additional pages if necessary•.
54MM(TTAj.lM111C iONS
9.Total well depth below land surface; 0( _M) 2,11% For all wells; Submit this form within 30 days of completion of well
1%ar mcdiiple e•ritr Jiu nfi d,peke efdA erenr(rrample•3@2110'and'n.100)
construction to the following:
M Static Water level below top of easing: l!J t/ (R.) Division of Water Resources,Information Processing Unit,
ff alerAe!Isalairecaring•cne'••' 1 1b117Hall Service Celt ter,IRaleigh.NC274"-1617
11.Borehole diameter. /l� (in.) 21h.Far iatectigp Welts: ht addition to sending the form to die address in 24a
12 Well construction method: above,also submit one copy of thisfform within 30 days of completion of well
0 C.au �,rn, construction to the following:
g. ,try,r•iAk,tlirctiK pttsl6 etc,)
FOR WATFR SI:PPI.Y'WF.i.LS ONLY: Division ofWatler Resources,Underground Injection Control Program,
'� 1636 Mail Service Center,Raleigh,NC 27499.1636
13a.Yield(gptn] Alcthad of test. 2.1c, Iff)r Witter Sgnnly&[giccHon Welts: In addition to st.'nding the form to
the address(es) above; also submit one copy of this form within 30 days of
131).Disinfection type: - Anoint: _ - completion of well construction to the county health department of the county
where constmeted.
I'nnin GW I North Comlinn rxpnnment of iin.9rdnmwtal Qnalij.-Division of Water Rosoorces Revised 2 22-201 ti