GW1-2022-01089_Well Construction - GW1_20220107

Feb 15 19 05:43p Clearwater Well Drilling 828-622-7241 P•1
WELL CO�NST1<tUCT10N RECORD fGW.-1) Tor Intcfnni Usc Only:
1,Well C intractor information: I
14 WATER ZONES —
►it01 Conora�ix Name rteoK To DESCRIPTION
Well Cnnnaetar Certification Numiier I 1S OUTF,R CASING formuttbpsed221 OR LIVER lfn lirxhle
0 1n 1��1/l (� /'I, —PROM TO DfA LR MEMO- MATERUL
.1 It�/ 11�JJJ� 1 `/�/li (0 1
Cnm)t+,ny Name v
i t \ I _O 1/ /1� 16.rNNER CASING OR TUBING thormd closed-loop)
2.Well Construction Permit#: U'J of C0 "r Rox I TO I ouMCTFst L TItIC:Ness NIA
i.).rt all appflcahle well canutueliaa permits(l.e.MG.Coaaly,Stale,Vartanev,etc) Et. k. in.
3.Well ilia(check well rise): n. h. in. -
Wa ter Supply Weil: 17.SCRUB
N
FROM
Agriculhrral �MtmicipaUPuh)ic ( n, ro ft- DIAMEM SLOTSIZE TnrcrcNttss MA (A
TEAL
Geothermal(Bcating%Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) I&GROtfr
Irtiaotion FROM TO MATE 1At rsT7PP.ACEME`tT. Eructo&AMOuNI'
Nnn 11'nter Supply Wr.11: I ft. ft -
lvlonitoring Recovery fr. ft.
injection Well:
ft. R.
Aquifer Recharge E3Grmmdw¢ter Rentcdiation A SANr11GRAVEL PACK tifeanliculdel
.Aquifcr Storage lmdRecovery DSalinityBarrier FROM TO MATFJ F7tt FIX CEMiiNTMLTllIva
Aquifer Test QStormwater Drainage.
Experimental Technology [JSuhsidcncc Control fa tr.
Geothermal(Closed Loop) ©Tracct 20.DRILLING LOG Winch Midi anal newsa
TO D ION r, wW,oektrpe,ar>•tnstu,etc)
Cieatherntal(Hearin oolinR(�Rca,rn) 0t6er(explain under$21 Rcmarf } FROxEt. ft
d.pate'%'ell(s)Completed: —/ Lai-a�Well IAfl
Su.Well location:
rya �- ��Ielc� l�P.in �(7prr.
I acilih:'�lutTcr}tamc Fa7lity[Dif(rfapplicablr.) a, ft
, k)0,& R. k. -JTN--7 2o2g �.
physical)Addrms,City,and Zip f4 R r'n i e't I 21.LtEMARNS
County Parcel Idemif cation No.(P[Nt
ch.Latitude and longitude in degrees/minuteslsecondsor decimal degrees:
(iPwollfield,onelatNingksutiietent) D a t ficnli n
4tV
6.Is(arc)the well(.$)i X6Pcrmnnent or ©ITempor•ary signnlure nrcenir�l ctl imtrnctor Date
���""lll !ry aflmutg tlod'..rm.1 here-AV crHlj):that the ttvdl(4 xar(were)cTmomeAvl in acchrdancr
7.It this a repair to an existing well: oves or No udrh PIA 4'!_"Af.'02C.0100 or*15A BCAC 02C,'.0200 WellC�nrlrtrctirur Mandardi and that a
/,t'rhfcirnrdmir.,011+n+tkrmwnxcl/aoearrurianinformalFaaA tnpp nflllif rr"Imil bas,hem providedin the well nwiter.ellnwiter.
mpair under A21 rema&*.V(rrlalr ttr as tin:bor•k nJlbn.fnrnt.
23.Site diagram or addit)onnl welt details:
R.For GcoprohelDPT or Closed-lamp Geothermal Wells having the same Vou ntey use the back of this page to provide additional well site demils or tuell
w.nstnirtion,only 1 CTW i is needed. frtdicote TOTAL.NUMBER of teens uxstruction details. You may also attach additional pages if necessary.
driHul:
[1II�i iTAI.INSTR IUJOAIS
9,TOW well depth below land surface: '[ ,(R•1 2,11% for All Wells: Submit this form within 30 days of completion of well
Pnr tatrhiplr e•elk lift all dopfhr ifdi,fferonr(crampl�d(n?1!!0'and fir.100') construction to the following:
Ill,Static Water level below top of easing: ( 0 () (ft.) Division of Water Resources,Information Processing Unit,
V"eah t•1-4 Is Above caving. ,At,",^t 16171Mail Service Center,Raleigh,MC 17490-1617
I I-florehole diameter: U I la (in.) Z11h.For laieclion tWIr- In addition to sending the form to due oddregs in 24a
I2.Nell constrnetlan method: above,also submit one copy of this form within 30 days of complexion of well
(i e.Anger,mt;uy,cable,tires ptab,etc.)
construction to the following:
Division ofWater Resources,Underground Injection Contra)Program,
[13a.
OIL WAT CR SUPPLY WELLS ONLY: 1636 Mail Service Center,Ratelgh,NC 27699-1636
Yield(gpin) liethod of Peel: 21c. IP(rr Y1'ater Sunot}&faiecHan Wells: Jn:rddilion to sending the form mthe oddress(es) above; also submit one copy of this forth within 30 days of
3h.Disinfection type: Amount: _ _ completion of well construction to the county health department of the county
where wroquticted.
Donn 0W.I Nonh!nrc+lrnn t�cpnnment of lin.irnnmrcml gaality-Division of Water Rogaurces Rrvisal2 22-20I6