GW1-2022-01058_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 P'1
WELL CONSTRUCTION RECORD i gW-1) For Inicmai Use Only.
1,MllContmetorIn!'ormalfon: [_
y t4 WATE ZONES
Ye Tn DESCRM'"ON
Well Coll Mal to ft.
1 LL_ ft. EL --
NC ell Cantrador Certifiea Mn Number QQQ r///�y S QUTFR CASING(for 010-rt W ells ORLNER ifn itable
MUD
W 6� � 10 t�OM M DIA 'fi1ttRQ M MATEnUL
ll V , it. a. t( � in.
C.amnany Nome /�(//A)��^( -16.INNER CASING OR TURINC thermal ttnted4co
2.Well Construction Permit#: fuf+-br.M->rll (J� fROvi I TO f DIAML'TFA THICKNUS I MATERIAL
i.lrl all applirnhle well a monrdion permits(l.a 1IM County,Sld/r,Varinneo,elf..) Ef. ft in.
3.1YeSl llgc(check well use):
Water upplyweR: —FROM TO I DIAMEWM I SLOT SIZE I TnICIOMM I MATERIAL
Agricultural E)Mlmicipal/Puhlie O R, ft- is
Geothernlai(i3eating/Cooling Supply) Reaidentia!Water Supply(single) ft- iL 10,
[ndustrial/Commercial Residential Water Supply(shared) 18 ROIII
Irri af1On FROM TO A_ Al, ts'M1MAC MTVT?es OD&AM1tOUNT
-Nne-Water Supply Nell:
M
onitoring Recovery u. fr.
Injection Wc]:Aquifer Rt cbarFc pfroundwntcr ltsmcdiatinn ft. R
79.SAND/GRAVEL PACK ra liesblc
And Recovery [).salinity Rnrrict pROs1 TA MATERIAL LACENSNTMLTIiOn::9
2rTrsi ©StnrmwaterDrainagc M ft.imental Technology 13Subsidence Control ermal(Closed Loop) Tracer 20.DRILLIIqG LOC ai ehaddl alebeet�irnectm
ermal{Hearin oolinRRcn(m) Other( lain under021 Remarks) rooms to ro D>s N enter. rtism,sow,ro/c4r ralae etca
a.Date Well(s)Completed-1 '_o�_Well IN
Su.Well I.nrntinn:
ft. O R `` -
Mq (fit tde�s ft. >t.
lrsrilih:'()xmcr Name Facility(DO(ifappl:cahle) n' R-
�J nGl �ie1d �(7uj , le�ceS-� IBC. :
nP� .dresxrC,ity,and
21.REMARKS
C,unry Parcel idemifecntion No.tPiNt
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �`�
(if well field one latlong
is
)
O � 0 'i
r�tifra�ti on: -%,TPSECTI
.R_�
111 ,V � � I(
b.Is(are)the well(sOr"n went or ©ITrmpnmry Si nalurc orcenifial Well Conurcror Date
by up'nong dill firm?,I herrhv crivf)+that thr twd1(4 mw;Cwerv)mramarrul in acmrdwrce
7.is this A repair to an existing well: [3Yes or No *41h iSA W!'dC'02C.0100 or*15A NCAC 02C.0200 rt'rliCr mtmenan 59ondatdc mid rho a
+'rhlr s n rcpair,f ll mak7tmvn infarmetian v1 arplain dw annire r frh, taRV rrfl/rle rcrrxd has OPt7r provide io the wdli nwwr.
rrvoir under B 21 rcmarkc scCgtm or do lire hurl of thRr forrn.
23.Site diagram or additional well details:
R.Par GeoprobefDPT or Closed-Lonp Geothermal Wells having the same 1'ou may use the back of this page to provide additional well site details or well
amslrtection,only i C*W-1 is needed. Indicate TOTAL NUMBER of uclis construction details. You may also Attach additional pages if necessary.
drilled'
I ^� �(1jtt,�fTTAT�,i�STRU(.T(ON5
9-TWO wcil depth below land surface: 1Yl _M) g4,y, For Ap Welts: Submit this foot within 30 da}s of completion of well
l`rr nrulrirle went lite aft d.Wile ifd*r mr(efama/e-3(a ANT and s a 1001 construction to the following;
In.Static water trvel below top of easing: (ft.) Division ofWater Resuwrces,Information Proeessiog Unit,
!!Wale).).lure.is a)uva cmlag,uac 1 161711fall Service Center,Raleigh,NC 274"4617
I I.Borehole diameter: �� �l7 1(/in�.j 211h.For laJecrien Welts: In addition to sending the form to the address in 24a
I Wc1i construction method: 1 IJL►�--1�T_ nhnve,also submit one copy of this form within 30 days of completion of well
construction to the following:
0 C.auge•,rotary,table,dirmt ptuh,etc.)
Division of Water Resources,Underground injection Control Program.
MR WATER St:PPI.Y WF,I.LR ONLY: 1636 Mail Service C.entr:r,Raleigh,NC 27409-1636
13a.Yirtd llvm) 'SDMethod of test r 24e. For W for Supply&fokellon Wells: In addition to sending the form to
the addicss(es) above:; also submit one copy of tbfs foot wi0lin 30 days of
I.M.Disinfection type: Amotmt: completion of well construction tD''the cormty health department of the county
where constructed.
Fnnli M.I North Canolion Dewment of En imnmcrral Qnatity-givismn of Water Resonrces i Revisal2-22-2016