GW1-2022-01056_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 p•1
WELL CON§TRUCTION RECORD(GW-1) Fnr Internal Use Only:
1, ell C,nntractor inform/attion:
WATEREt1NES --
rRort Tn pESCRnriON
Well Cot nowt Name to ft.
3 ft.
/Nyt:Well OinntranorCertificatinnNnmtier —I&OUTF.RCASING rormntAsssedwellsOR LINER(if o irable
1 tl//I�f�dt1,t n �� WI IatOM f4 O. DtAMC7ER in' 'r11(t7(tiEBS MATERIAL
Ca;npnnv Name — C
16.INNER CASING OR TURINC ORF111311i cirtsad4oa
2.Well Construction Permit 9: L _ v`' ` ��O TA DGMEIEA rntcwtvEss MATERIAL
idst all applicable UJC.Courtly,Stale,Variance,cK..)
in-
3•Well ilie(check well Ilse):
�17.SCRBEN
Ws ter Supply Weil: mom— to DIAMETFAt SLOT3OS TRICKNIMS MATRR6IL
Agricultural 13Mtmicipal/Public () R. !i. in.
Geothermal(l•IcatinglConling Supply) NKResidentiai Water supply(single) R ' tL in.
indusiriaUCommereial Residcntiat Water Supply(shared) I& OOUT
lrri^ation _111 ii TO MATERIAL BMM.ACRME`FTM. D&AMOUNT
Non Water Supply Wj,.Ij: rt" AL O"
R4anitoring Recovery
injection Weil: -
f1. R.
Aquifer Recharge E3Grmmdwater Remedialinn
19•SaNnIGR+tVEL PACK if o liable
Aquifer Storage and Recovery Salinity Bnrtier PROM TU 51ATM F]It►LACE
AL MENT ETuoD
AquiterTcst ©st ormwater Drainage
Lxperimental Teclutology O3ubsidence Controt ft R•
Geothermal(Closed Loop) [)Tracer 20.DRILLING LOG Wife h ad tl al sttaet5 if neonsa
FROST To 0E5CR1 N color,hord aawil/rakr raMrlu,ete.
Genfficnnal(Hearin aolirtR Rert,m) Ufher a lain uttdcr 821 Remarks) tt. !r_
WE
A.date Wefi(s)Completed: _L_Well 1D11 fr, t�Dft.
5u.Weil I.nr"fink NFL
F:tcilit);'(ktrsCi llarnc acility IDit(ifanplicaUt) R' ^?
strnl Address,Ci ,and 7 p fL n ribt'.1?lu"
21.REMARKS
Caunty Pnrcel Identification No.(PiN)
Sb.Latitude nod longitude in degrees/minutes/seconds or decimal degrees:well fey,one laMang is suiiicicra) 6 t ?2.ice frotion:
6.js(are)the well(s)�[@Pcrmanent or Temporary tiignalarc of Certified Well Contractor Date
77��� JFn,ct/niag dN.r form.J Henrhp mflif•that thr lwdl(.,)was(warr)crmontlye 1 in acerrd'ame
7.Is this it rrpair to an existing well: QYes or No xdrh JJA N(!AC 02C.0100 or'15A NCAC 02C.02110 Wel(C:'uttslncttnn Slondards enid that a
6"Illb it a repair.fill ow hwm well c:onslttlettaa igfarmatiao t rsplrtar Iht.nanrre.r,lthc copy nfllt(r rtkY�td Facllvtvt(Jralgd2illQ Mt wril Mvder.
r:aairlmderR2lrcmarkc.rcrdnnnrnar/rchacknfddxfarnt. 23 Site diagram or additional wclldetails:
R.Par GeoprobdDPT or Closed-Lonp Geothermal Wells having,he same Yuu may use the back of this page to provide additional well siie details or well
eonaintction,only 1 G%kf.l is needed. Indicate TOTAL NUMBER of.,%mils convtruclion details. You may also'attaeh additional pages if necessary.
Q �IBM[aAl.IDMilcaONS
9•lrotat well depth below land surface: L) ° S (R•) 24% for All Wells: Submit this form within 30 days of completion of well
My tauhiple wells litr all d eprlw ifdi,jferent(eramn/c-3C Joe-and i£(li.100) construction to the following:
III,static water level below top of casing:. ((t.j Division of Water Resources,Infillrmation Processing Unit,
ffwalrr lerc!is aJ•nve cursing,ale"-�"l I� 1617 Mail Service Center,Raleigh,NC 27499-1617
11-Borehole diameter; lJ� (i�n.j Ub.For[aiecti n Wa111: hi addition to sending the form to the address in 24a
It Weli construction method: construction
also so the one copy of this form within 30 days of completion of well
cl:(tstructian to the fallowing
(i C.Ntj;c,rotary.a>hk,dirttti prtsll,•XC.1
Division of W ater Resources,Underground Injection Control Program.
POR WATER 8l:PP1.Y WEI,L.s ONLY: 1636 Mail Service Center,Raleigh,NC 27499-1636
13a.Yield(gpm) Method of test: Iy 24c. Ilnr Water SDBRIY&FRiMHon Wells: in addition to sending the form to
the addwss(cs) abave, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: Completion of well construction bD the county health department of the county
where constructed.
Dann Gw-1 North Camlini Dcpnament of i;n ininmcnmt quality-Divisinn oPwater Resourr"I Revised 2 22-2016