GW1-2022-01074_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 P'1
WELL CONSTRUCTIQN RECORD fgW_-I) ]'For Internal Use Only:
1, 1CQQon�,//trattarinformation:�y it
05 T 14 WATERLONES Well(:ollncl x Name FROM ;—To, DESCRIPrtON
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NCC:�W01 enntraclor Certification Mutnhm � s.OUTER CASING: for multi-cased welt LI OR VER a licablt
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IDIOM 7'O DTAME7LR 1[f]CNYP MAl'ERIAL
�t6.INNERt;ASING Oft TURti G thormdcrnatd-too
2.Well Construction Pennit#: IJIJ 1� L " �T `+ PROM I TO DIAMETER I THr0 arms MATERIAL
i.).rr rdi o/yrlica!rte well cnnarodial parnritr(l.e.UIC.Conroy,Stale,Purianrv,efc..j Et. tt In.
3.Well Ilse(chock well use):
Water Supply Well: 17.SCREEN
AgricuhuralMimicipal/Pubiic (�OM R. TO tr. niARNETtat SLOT .H THICKIV MATERIAL BSS
Y4leahermal(licating/Cooling Supply) a8eqidential Water Supply(single) ft. tt
ridusirial/Commercial Residential Water Supply(shared) &GROUT
irri^atl0n _Kn0 TO MATERIAL SM PLACEMEVYM THOD,&AMOUNI'
3Ynn-'1'nttr Supply Well: tt• C) IL `
It4onitoring Recovery
injection Wctl:Aquifer Recharge E3oroandwn ft. ft.
ter Rcrucdiminn I9.SAt!tTUGkAVEL PhCK fo !' ble
Aquifer StoragetmdRccovcry E]SalinityBarrier PROM TO tNATC81 L EMPLACEMENT METHOD
Aquifer Test ©Slnmhweur Drainage PROM
Experimental Technology [jSuticidenca Control It. tr.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG aitan additional isheeft Ifneum
FROM TO 1►E5CRi N color. rye®,Fpkh mk f rat"s etc.l
Cieothennal(Hcatin ooiing Rcntm) Other(explain under 821 Remarks) �- ft. !t �, � ,}•
4-Date Wttl(s)Completed: 4 3a1 Well IDH (`n/ ft• tt• ,
Su.Well i.00:atlna:
f►. R.
��c �2a Rohl� � b3fr. - S••II.
l:tritity:'(lnncr�famc 6 'IityiDi!(iftpplicable) n' R•
Thylssiirnl Address,C ity,`an4 Zip 3` V �CA —1 vl l _Lp lY to
l Ql R�M R
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CA011ty Pared rdcnufieatitm No.(plhl fq
Sb.Latitude rind longitude in degrees/mrnates/seconds or decimal dcgrecs: .022
(i;aelt field,one lamong is snf icient) v r e u Iratone D!Nt
G r ° s�cl-i0�;
i _ �+ Y ��a � 53�- INFGRMATI :I t s
6.is{are)the well(s)dr-manent or ©ITemporary Sig arc orcent�I Contrnetor rate
PV.u/m(gg dne,trrm,I herwhvc-rtrifi:that tkr twdl(g)rtnr lwm,)amoracYul in oecnrdenee
7.td this a repair to an existing wen: Oyes or bNo ndtl,13A NC:'AC10W.0100 or 15A YCAC 01C.'.0Xt0 Welt Gins/n+rruur 59andardc and AM a
,"twi i. ;repair,(Al mrrknonw Wulf rrxarrrncrian urfarma;Ian taut uplain Me,witire nfnc� tnpP afrhtc rrronl hosAes�protddr.Aln7lu w1rf1 mvrur.
r;Wir and r 01 remarkr.xhnhal or on ifn:hark.afthic form.
23.Site diagram or additional well details:
R.For Geoprohe/DPT or Dosed-Loop Geothermal Wtlls having the some Vou may use the batik of this page to provide additional well site details or well
W-nsiniction,only I GV,r•l is needed. Indicate TOTAL NUMBER of k%rlls corlstractioa details. You may also attach additional pages if necessary.
drill-ad: �.I1` '
�T� � G�1.IR$T,.�UCTIONS
7ro�• tal well depth bolmv land surface; _(R.) 24a. For 11t1�}'elts: Submit this form within 30 days of completion of well
r%�r nruhipfc>r•rNs Uu all d Pl4r�dijfenrrt(r�amole-t(a1390'and e�il00� construction to the following:
10,Static Water tl'NCi below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
/f+rat slur;t h rrlvrvs tnr/ng,v�''e 1617 MA Service Center,Raleigh,NC274"-1617
Ii.ltorcholediameter., t V (in.j lib.For tafection We11V h)addition to sending the form to the address in 24a
12 Weli construction method: -'( above,also submit one copy of this form within 30 days of completlon of Well
(i c.au•r,ro, construction to the following:
b. ivy.cable,4irtAti p1os0,�c.)
Division of W ater Resources.Underground injection Conrrol Program,
MAI WA'I .R SC;pPI_Y WELLS ONLY: 1(36 Mail Service Cenmr,Ratergh,NC 2709-1636
13a.Yirld(-pat) Method of test: 2:1C. for A'atcr SnpQlt &faicchon Wells: In addition to sL-nding the form to
the addresses) above, also submit one copy of this form within 30 days of
13b,Disinfection type: Amount: camplction of%vcll construction to the county health department of the county
M.—ennsttucted.
Form OW.I North Camlina Department of iinvimnmcntal Quality-Division of Water Resourer c� Revised 2-22-201 b