GW1-2022-01057_Well Construction - GW1_20220107

Feb 1519 05:43p Cleetwater Well Drilling 828-622-7241 P 1
WELL CONSTRUCTION REC0". {GW..11 �For internal Use Only:
1 lI Contractor information:
14.W TEONE5 —
"" 'rntON1% ,
DESCRIMON
Well('rntmaqur Nam ft.
NC Well Cnntractor Certification Number L(XITF.R CASING for mtilti•casW V-11hillOR LPIER if a titabte
TO DIAMETER TIIIl7rNPB9 M AULL
g., ft. in. C
nmpnny Namc ^ ( i y;/ 16.LKNER CASING OR TUBING ifigmal elosed-Imul
2.Well Construction Permit#: ')' , 'VJ1 (-Jl/�tl To ountErEtt THICK I MA•t ML
i.l rr ali oppliv zhie well cnwiructlrtr parmitt(l.e.INC C.otfroy,3tatrti Yartauca,cut.) ft. fL
n• ft
3.Well Ific(check well list):
�t 7.SCREEN
LVater SupplylVeli: ro nuMeTtsR suorsas TxtcKNrss MATERIAL
Agricultural Municipalftli c Q ft. tr.
G—hernial(i.•leating/Cooling Supply) JResideftlial Water Supply(single) O, tt in.
Industrial/Commercial Residcrnial Water Supply(shared) IS.GROUP
!Fri^ati0a FROM TO MATERIAL EMMACEME7ir34F. D&AMOUNT
Vnn-11'nter Supply W,11:
Monitoring Recovery tr. tc
Injection Well:
ft. R.
Aquifer Rechaf E3nrolindwatcr Remediatinn
19,SANIMRAVEL PACK f a licable
Aquifer Storage and Recovcp Salinity 1311trier FROM I To MATERIAL FItIrLACENIMT MUllon
AquiterTest ©SmrmwatcrDrainage f A.
Lxperimental Technology [3Subsidenre Control ff. n•
Geothermal(Closed Loop) Tracer 20. MULLING LOG attach adds onalahee 'if ."
FROM TO DESCAI%tON mkrr.turtaep.wWmtkt ratq�fu.ete.)
Genthennal(Heatin ooling R.catm) Other explain under#21 Remarlrs)
d,DateVl'et!(s)Completed. Well ID# fe. A-;V ft. /k--L—
Welt Location: j9fT
It. A4AA4K -
&:lcililyt'(lanct)lame Faeili y iDi!(ifarplicabtc)
Ph 'ral Address,City,and Zip
21.REMARKShl
Coumy Parcel W-mification No.?PBS) A -
Sh.Latitude nod longitude in degrees/minntes/secands or decimal degrees; "s r,.,t,.•., ..,.;,, .
(ir well field, ne la[gong is sufficient) 0
v-
6.Is(are)lhcwelt(s) Permanent or OTemporary gnoturcafC.enfrud WellCimtmetor Date
I?v..t}min$di t harts,I herwhv cwtify than the twill(%)was(ire l amvmt.Yul in accnrdonce
?.1a tills a rrpair to an existing well: OYcs or 10 x•ith 1SA.Ri:'AC7 A2C.?/OU ar 1JA.YCAC 02r.•J1TD0 Well C:'onrtnnrrwt 5tandoeda mud that a
1;'tlrfr is n rcpair.�!l ra+tknnwa udl.;oarrrrxtiwt infnrmatiun me capJ?in the woure.orrhv enpt,ofllat retord has hrem proMed lrt r/u:well owner.
r wi it under G?/rcmnrkt.rcrnnn or na 11n:hark of lhls jam,. 23.Site diagram or additional well death:
R.Fnr GeoprotwMPT or Closed-Lonp Geothermal Wells having the same Vou may use file back of this page to provide additional well site details or well
constructinn,only I GWA is needed. lixticatu TOTAL NUMBER nfwrps constructiDn details. You may also Minch additional pages if necessary.
drilled:—._.
-- -----•- ���� 9IQibtlTTnT,IrSTRLIGTt�NS
9.Total well depth irelow land surfocc: (R�) 21, to All Welts: Submit this form within 30 days of completion of well
Mc,f muNple-ell r liv ali deprArjdi�crert(eramole-3@10wand seal.1001 construction to the following:
10.'Static water level below top of cssimg- (ft.) Division of VWoter Resources,Information Processing Unit,
1/'surer lm.'.!It above coring.uu"--1 i617 Mall Service Center,Rateigh,NC 27699-1617
li.Borehole diameter. �(in.) 21b.For IRlectiQp Wells: in addition to sending the form to Ole address in 24a
� �J almve,also submit one copy of this forth within 30 days of completion of well
I2 Well construction method! "=-"� construction to the following:
(i C.aogm,rotary.C.*lc,direr posh,etc.)
Division of Water Resources,Underground injection Control Program.
Fa R WATER SCPPLY WELL 3E S ONLY: 76 Mait Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) .3(JT Method of test: 24e.Ivor Witter SuDniv&ipiecti•on Welts: In addition tin umdmg the form to
Me address(es) above, also submit one copy of this form within 30 days of
13b.Disinfectian type: Amount: _ completion of well construction to the county health department of the ctlunty
where constructed.
I ann GW-1 North Camtinn Dcpnnmcnt of tin.irrinmrntal Quality-Division of Water Rmloarces Revered 2 22-2016