GW1-2022-01085_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 p•1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only-
1, ilContrartorI ibrmation: I
P.1� iK �s _ �14,W TER ZONES
SVell Contradix Nalnt FROM Tn DESCturrlON
VC:Well CnntraAor Ce�rtifigcation NtTtrer f s.OUTER CASING for ma1(i•cased waft OR Li?Il3t a ]kabte
\ � txAtrrtaT R 'eIIICKNt3 MATER L
1111���SL�111 lll.���///Illlll i1 }Tj./_`�_Jj g, ft. an.
Cnmpnny Na„a I ^
16.LNNBR CASING TUBING
- O"(,.[J tttormat elealddoo
2.Well Construction Permit 9: 1.�._._, FROM I To DIAMETER TRICIOWS MATERIAL
idw all olyrlicahle we11 cnnrtntatar µrmiGt(f.e.111C,Caaaty,Stale,Varlam•e,ct:.) .. ft• h• in.
3.WIN Iric(check well use): n•. Ih. i -
Water Supply Weli: 17.SCRBEN
FROM
Agricultural to rat MCfM st T=r, TRICuxtrss MA7&RIAL
�]Mrmicipal/Puhlic () R, fL in.
Geotherntal(Heating(Conling Supply) Residential Water Supply(single) q• f in.
htdusiriaf/C,ommercial Residential Water Supply(shared) &GROUT
IRiantion FPW TO ATl;IitAL sMM.ACE E#TM OD1kAWV0tJW
Non-R'nter Supply Wr.11: ft.
[!AqUif,.,rStqr8I;C
ring Recovery ft. fr- -�•--`aka
Well: -
ft. R.
Aquifer Rmcbargc QGrotmdwater Rcmcdiation Ig•SAND/GkAV1;L PACK Ie ieable
MdRcravcry E]SalitlityBarrier trRt►M TO MA 1AL FItt1LACEMB(VTb1L7upa
Tcst 0-stnnRwaterDrainagemental TechnologySubsidence Controlmal(Closed Loop) 0Traccr 20.DRILLING LOG attach a,iditiodalsheets ifneeessaTO Dr.SCRIrrION eator.harsa®.scghvck t ratn Aw.etcdrmal(Hearin Coo[inR Renurn) Uther(ex lain under 821 Rcm trks} ft. fr
LIU0 r.
4.Date Rrell(s)Cnnn eted: ` "ZA WCII iDY ft. fLCt �•
1
Su.Well LncaHnn: -Awe '
AliSWa EradV) .00L� �' r e
Ptcilih:'t%werlHaamme Facility[DO(ifapplickble) ll. R �`,) ` ..f __:I.'i•
Ph- I Addreas•City d 7.iP r— R. rL 202
� n 5 r 21.REMARKS
CatnuY Parcel fdcn6f(cetion No.(P1N) :'`t 4 I I0%v
Sh.Latitude and lonRitudr in degrees/minutes/seconds or dccinut degrees:
6"wDll fictd one lattlong ix sutrldcnt) t2. a anion:
6.Is(are)the wells) Permnnent or ©rfemporary si c ofCc lificd Well Cantmctor Date
13v,tllmiag dN.r.;%rem,f hrwhv crnj&rhal thr nrJ x)mar riren j crmsrruMa!in acnnrdance
7.1s this a repair toanexis8ngweft: E3Ycs or No with LIANCACO2C.0100or13A.YCACO2C.0200MOC..unrtmrnonVaxdaedr Mid Ama
f"'f/dr i.,a repotr,ill tna kna nrr ur11 uoaunnrian irtformanwa eri""the luvvre rf the copy nll/rfc hrrnrrl hoe APQ7 f1MWrkhf M the m!i/nwJier.
r•!,70ir under 1:11 remake sccrran or na llie hark of this farm.
13.Site diagram or additional well details:
&For Geoprohe/OPT or Dosed-Iwmp Geothermal Wells having the same, 1'ou may use the back of this page to provide additional well site details or well
mnsiniction,onit i GWI is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifliocessary,
drilled:—
.—
` �UIIME[Ul,I&M-1.1t:TT�NS
9.7rotal well depth below land surface: v T00 2
Fur M1111WE" h IA'art d•lrthr iftfiferert(eromolc-Jo100'amf 2@1001 ta. fQY� ells: Submit Otis form within 30 days of completion of well
construction to the following:
, inane wetter level below top of caning: Division of Water Resources,Information Processing Unit,
IJ xalr!'icrc115'erlvlrncQ.rhlg,rRW ' 1617 Mail!Service Center,Raleigb,NC274"-1617
(
11.Borehole diameter:�:Y��(in.j 2tb.For IniccNon Wells: LI addition to sending the form to the addnoss in 24a
I Well construction method: 1 V±" allove,also submit one copy of this form within 30 days of completion of well
6 C.align',rotary.nelblc,direct Ptah.etc,) construction to the following:
[11'3a.
R WATER Rl;PM.V WELLS ONLY: Division of Water Resources.Underground injection Contra)Program,
n , 1036 Mail Service Center,Rale4h,NC 27699-1636
Vicki(gpm) Method of test: Ili 11c, Far Water SuM &iaketion Wei: In addition tosending ahc form to
the address(es) above, also submit one copy of this form within 30 days of
b.Disinfection type: Amount: completion of well constiuction tD the county health department of the county
where constructed.
Forni CW.I North Cnmtina tVPnrtmem of 1in%ininmentnl Quality-Division of Water Resanrcaa Rrviseel2-22-201 b