GW1-2022-01048_Well Construction - GW1_20220107

828-622-7241 p'1
Fete 1519 05:43p Clearwater Well Drilling
WEiCLL CONSMJ&TI0N RECORD(GW-1) For ln(cmal Use only:
t,MIContractorinformation:
�I WATEF ZONES V
well Contractor Kann: r N Ta DES RIPCWN
vt:Well Cnmmelor Certification Ntrtnhet S OUTER CASINti for muld-cased wells OR LiVER if apdimMo
1 q I Imam To __J D1App I -01ICKNESS MATERIAL
ft, ft. 1 in.
Ca:np+my Name
16.INNER CASING OR T1tAING thormal efoaed-too
2.Well Construction Permit 0: PROM TO I DIAMETER L THICKNESS MATERIAL
i-l.rt all op/Aimble wet/Cnactructlen pamiir(Le.I/1C.Cnuniy,Stale,vartaace•cm) N. k. in.
3.WrJl ific(cheek well Ise):
Wa ter Supply Well: 17.SCRURN
FROM TO DIAM"M 6LOT41Zt3 THICKNESS MATB1[UL
Agriculhtral Mtmic)pnUPuhlic 0 It. ft in
C'Whennal(licatiug1cooling Supply) Residential Water Supply(single) R I fL in:
(ndusitial/Commercial esidentiat Water Supply(shared) I&GROUT
Iftq itrn _FROM To MATERIAL rWilLAt B!IT. IiT71 DdoAMOUNT
Nnn-�i'nter Supply Well: fi- IL
[XIring Recovery to. ft.
Well:
ft. R.
Recbatgc QGroundwater Rernediatinn -I9.SahllllCkAV6L PACK a li ble
Storage find Recovery E]$alinity Barrier FROM To MATTRIAL 1r CEMSltTML7[IOn
Ten ©5tannwaierDrainageental Technology (3Suhaidence Controlmal(Closed Loop) 13Tracer 20.D i.L1NC Lt)O tlitaeh aleaswtRROYi mfor hard>.m.roN/nxk t ra{n�funal fHcatin acting R.en,rn) 0ther(ex lain utWor 021 Remarks) tL tr
d,Date Well(s)Completed: iU Q�_._.l•Wcll IDtJ It.
apO�L
Sou.. IWeelll LLWAtlon. /�t�® V[ �
i'.t 'ity;'(lus,cr!lamc Fa'N [Oil(if applicahle) n' R. '
P i +I AdArcae,City,and Zip_ R R `
-�—.-• 2l. ARKS
County Parcel rdetnifiention No.(PiN1 I I�Ir
Sb.Latitude nod longitude in degreesiminutestseconds or decimal degrees: J A N 02'
(if av+ell rickl,one laC9ong is sufficicM/ O r 2.Cet'tifi inn:
ao
no
IMNIR SECTION
W ���L.�rt}_r','n!"iia��i,-,raC��'P•3��i����i
6.h(arc)the Well(s) ermanent or ©!Temporary SiQnn Centfied well Ctmtractor Dote
19t+alyning 0in•.6)m,1 hetwhv ecirlfj:thus/he tw.!!(a)mrr(wen)rrgcttirmhvl in acwtdonce
7.is this Arepairtoan existing well: Oyes or o w;rh1JA.tir-,rCO2CA100or1JA,YC.AC01f.'.02(10 Well CrnsirnCtiarSlandardrnnfAma
,t'd is iv:�rcpair..�11 nutknnnm will,:oactn,ctian i>tjnrmalian wa1 rrplrnn the whirr q/uAc Cn�y nflhfr h'tv,rcl hacAeen pMtHde�d 1n the w+7ff nwllrr.
r"air under t,21 remnrtcc.scrrintt rtr on 11n!hark of ihh.iirnt.
23.Site diagram or additional well details:
R.Por Genprohe/DPT or Closed-Loup Geothermal Wells having the came Vou may use the back of this page to provide additionn)well site details or Nell
construction,only I GW-1 is needed. Indicate TOTAL,NUMBER of o-iclis construction detaiiR. You may also Attach additional pages if necessary.
drilln:cl:
.—..- — ._- Q n �,QRMUJAi,iNMUMQN8
9.'Yolat well depth below land surface: VL ,(4.► 2,11a. ForA�W-01i Submit this form within 30 days of completion of well
17frM1flt%lulu%Yl/r/ilrafid�prAe ifdi�er..ar ir�a,ao��-an�no•anr�•n tangy eonmmuian to the following:
IiI.Static water Level below top of easing: WO (ft.) Division of Water Resources,Information Processing Unit,
1%e'ahY hre11r,rlvivacavmg•ttu"•'L 1617 Mall Service Ceater,Raleigh.11274"-1617
Ii.%Mhotedinmetcr: L (in.j 23h.For IRleetion Webs: AI addition to sending the form to the address in 24a
12 Well ctmstnlCtloR method• armve,also submit one copy of this form within 30 days of completion of well
�, It)rn, construction to the following
0 e.Mg- I •.cable,iJirCCt posh.Cue,)
/FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground infection Contra)Program,
1636 MDit Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 2-le. If or Water Cgpdv&iiliection Wells: In addition to sending the form to
the address(es) above; also submitjonc copy of this roan within 30 days or
131i Disinfection type: Amount: completion of well construction to the county health department of the county
where cor�tmcted.
I+nnnGU•'-1 NonhCnrnlloot?epnnmentoflim9rrinmcat�lQ+�ality-DivismnoPWalcrRosaurerc RevisoA2-2�2a16