GW1-2022-01022_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 P 1
WELL CON§MCTION REgQRD(GWI) For In(cmai Use Only:
1 getIOintraetnr nformation:
LONES
PROM Tn APSCRIPrrOY
Well('onlraatx Name rr fr.
VCVC Wrl r Catificatinn Nannher //�� S.OUTER CTO for m-DIAI►sedl wells OR LI?ili7t Ira ieMI11101
AT
/� - �/ y nuOAt M DIAMETtR 'r11ICKt1P6S MATERIAL
IL-1✓A.�je1 `mil fr. 0. 1 in. VC-11
COMpany Name
�� _ q1� �j C �1 INNER t ASINGQR fURINC drormaleluawfaoo
2.1Yc11 Construction Permit#: [/lJl.r�t J trtto>+ 5�—Afl-
WateraL►ntctTs+ ratct:dess MATERrA4
0-0 ali allp"JoThle well cnnenrction tom ru[La.tl(C.Cnuniy,Slate,Variance,cm.) tit.
3.Well Use(check well use):
in_
Supply Well: 17,SCRIIEN
FROM TO IMAMETFM SLOT SIZE T7dICKNPSS MATEQUL
Agricultural r)Mlmicip imblic Q ft. n_
Geothermal(I.•Icating/Cooling Supply) Residential Water Supply(single) it, ft. in.
[ndustriat/Commercial Residential Water Supply(shartxl) lA,Z;I T
IRi�atiaa PAOM TO M A EMPIACEME.T. ETFtODdc AMOUH7'
PVnn-�1'nler Supply Well.-
Monitoring Recovery
njcction _
ft. R.
Aquifer'Recharge Groundwater Remedialinn 19•SA I t.GRtIY&L PACK f a livable
Aquifer Storggc and Recovery DSalinity Barrier PROM IM MATERIAL FIVRLACEMBnT MCt H"
AqujrcrTest QSmrmwaterDrainalgc re rI'
Lxperimental Technology [)Sultsideneo Control R• R•
Geothermal(Closed Loop) [3Traccr 20.RRIi.LING LOG munch oddidoalaheets ifttaoessa
TqnPROM m TO DiSCRtPT10N lor, ads user ralaftu,ete,l
Geothermal(Kcatin ooling Remo m) Other explain under R21 Remarks) it. n
A"i 2te'rYell(s)Completed: _Well ID# ft. D
-
rUK1 ft. R
Su.Wrll1-ncatlnn V _
Lr f� S n.
Facility"Omser}lame Facility mid(ifopplicable) R. R
sirnl At dress Ciq,and 7-i f �/ rL h- n
21.REMARKS 7
caul!! "O ?'
Y Pnrrcl Identification No.tPilvl
Sh.Latitude and longitude in dcgreestminutcslseconds or decimal degrees
'�(ii e,+ell field(,,fonne�latgang is�itliciem) s ue( +
02 ` 1 `��S V D � �JU t 9�� 4Y 2 rtificatinn:
Oper
4-15(are)thewell(smnnent or ©!Temporary SignmurcofC'enifwdWellContrnetor Date
Iry sjpwnh rhtx.frrm,1 hvPrAv errrify chat the VWdl(.)was(wad)cTmanerfe<l in"emdance
1.1s this a repair to en existiag well: OYcs or No with 15A NC,IC 02C.4100 or JSA AC 02C.0200 Well Conrtnrr.•nnu Slmdardi a m!that n
!r'thls iva rcpair.,jr!!outknawn will r�oaarnctinn infa,moiion .rplain the nnnrn�q(nc� cnpt af1ldr rrrYrrr!hoc beam protvde•rlln/he wc!!nwrur.
r•.polrrmder R:!rcmnrlasallmrrN'nn1ln:h�cknflhfs.forn+.
2..4.Site diagram or additional well details:
R.Par Genprobe/11PT or Cdlsed-1 onp Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
mn-91nlctinn,only I CTW4 l is needed. 6ldicato TOTAL NUMBER of-•ells construction details. You may alsoattach additional pages if llrcmarv.
dril(4!d!—__...._._ ._... � �MQMRTAI._1nSi'RiICT10NS
9.Total well depth below land surface: (R•) 24% for All Waits; Suhmit this form within 30 days of completion of well
b6r m'111 plc consultation to the folloteillg:
l0.grade tenter level below top of casing: - (R.) Division of Water Rewourees,Information Processing Unit,
1!•x'alrrkw-!Isrehora raving,
ine('•' ( 1617 h1all Service Center,Raleigh.NC 27490-1617
I1_Borehole diameter: V" I�-/ (in.j lib.For injection Wells: In addition to sending the form to die address in 24a
I Well construction method: above,also submit one copy of this form within 30 days of completion of well
construction to the following:
0c.augc,rnGuy,cable,dirttt pleb,IXC•)
Division of Water Resources,Underground injection Control Program,
EVirld
SCPPl-Y ELLS ONLY: t 1636 Mail Service Ccnmr,Rnla*h,NC 27699-1636
m) Method of test: 24c. Uor Water Suanly&Tnieeflon Wells: In addition to sending the form to
the addresgcs) above, also submit one copy of this form within 30 days of
on type: Amount: completion of well construction to the county health department of the county
where constmcted.
1+non C14.1 Nonh Crue+lina Ucpnnmcnt of Fin,imnmentnl Quality-1xvim nr of water Resources! Revised 2-22-2016