GW1-2022-01090_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.
I.Well rAntrattor Information:
._L—LLtCa Y El I( t4,WATER ZONES
Well Crintragtx Name FROM TO DEstatrtON
1 V
NC nWN1 Cnntranar Certification Ntmther ?QUTF,R CASING for mat�/sed wells tJR LINER if a l xtrbit
U Q n n 1 n y �/� I I 1/r VROM TO DIAMETER 'MCKNFBS MATERIAL
`V\�^�))) `l
Cantpnay Name _
�' I ��p f 16.LKNER C 1NG OR TURING thQrmrtl closed too
2.Well Cons Permit Construction Peit M. 11U n �.l FROM I To I DIAMETER I TAICIllmss MATERIAL
i,lw all nppiicablr wcliCe rtruerloo permits(t.a.fl1G Cortray,Stale,6:rrlanea,cis;) ft.
3.lWil Ilse(check well list): Ir.
WafcrSupplyWell: I7 SCRBEN
FROM TA 01AMEM SLOTSM THICKNESS I MATERIAL
Agricultural E)Mtmicipal/Puhlic (1 ft- tt_ in.
Geoth—1(Hl-tinglCooling Supply) Residential Water Supply(singtc) g R,
[ndusirial/commercial Residential Water Supply(shared) I&GROUT
ltrigntion FntMr T MATERIAL EMPLACEME.`17M. TT10D8AMOUNT
Non-N'ntcrSupplyVl'tll: r+• n-
h4miitoring Recovery (r. ft.
injeelion Well:
fl. R.
Aquifer Recharge E)(iroundwater Remediation 19,SANDlGRAVEL PACK lifa liexble
.Aquifer Storage and Recovery Dsalinity Barrier FROM TO WIAT12UAL F1HlLACEMSNTMtTrtOn
Aquifeacst []Smnnwater Drainage
Wiped mental Technology [)SAsidcnee Control
Geothermal(Closed Loop) ©Tracer 20.DRfLLiNC LOG aitneIt alditionalstlaets ifncensn
-FROM TO DQCRiP1ION color.hNn4m ,wWrotkt rain Ow.etW
Cieotheurnal lHcatin Doling RcnrYm��)yy Other(explain under N21 Remarks) R. tr
A,hate WeN(s)Completed: —d l!- Well IDY fr. (t. M Al
Su.Well l.nrstlon;
l acilih^.(k+rice llamc 1.CJ Facility tDif(if applicable) R• ft.
Physical Address,City,and Zip� 2l. ft.' iL -DVVP S r ,a.M
a UNt7
C'mty Primal identification No.(P1N)
Sh.Latitude and tongltndt in degrees/minutes/secondsordccimal degrees:
(i"well rich,one latilong is sufficicnt)
(( as a r ff .t2. t tificAY n: q 1
ISLES o—,�) � .N t l W
6.Is(are)thewtll(s)*crmnnent or ©iTemptirery tiignmurcafCenifi w ICemnnetor Date
TT 1;v stpmiag 00.1hrm.I herrAv cwmfy that Me nvll(a)war(were)ixmrinwad in aunrdonce
7.la this it repair to an existing well: oVes or J/No with i.SA.C,,IC 024r.0/00 or 13A,YCAC.02C'.0200 Well Cunrrnreriar SYorularda mid chat a
1,01dr is v rcpair,,ill ourknnnvr ital.!Oaarnctina irrjarrnation rr rrpinin the anot a r.(tho tope aflhft revord haehrem protddat to the well nw ter.
repair under A21remark .'krrianrmnrrIln:harkefrhhjornt.
23.Site diagritm or additional well tleettits:
A.Par Genprohet7fPT or Closed-Lrtrip Geothermal Wells having the saute 1'ou may use mho back of this page to provide additional well site details cm well
mnslnectian,only I CT%'•i is needed. indicate TOTAL.NUMBER orwclis coat truciion details. You may also attach additional pages if necessary,
drilled!__ (11M TAI,INMUCLIONS
9.Fetal we11 depth below land surface: �.L _(R.) Y4a. for All }xells: Submit this form within 30 days of completion of well
1%arnodriprex•eflrritraridrprlcvifr(ij(errrr(example-+o2200/''aud2@1001 constrttctitmto(be following:
10,8tRtie water level below top of easing: Y- v (ft.) Division of Water Resnurees,Information Processing Unit,
1J'eahriciv.)snhrmacnstng,nxr"••I 1617 Mall Service Center,Raleigh.MC27699-1617
li_Roreholedlumeter--u ` 24h,For Iniection Wella: In addition to sending the form to die addraa in 24a
17.Welt construction method:,( above,also submit one copy of this form within 30 days of eompleuion of well
(i c.A"Be",to,try.cable,d irett push.c(e,) construction to the following:
g.
Division of Water Resources,Underground Injection Contra]Program,
17011 WATER SCPPi Y WELLS ONLY: 1636 Mail Service Center,Ralelgh,NC 27699-1636
r
1311.Yield(gpm) Method of test: 21c,For Water Supply dt iR)eclion'Wtll;-. in addition to sunding the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.01sinfeetinn type: Amount: __ completion of well construction to the county health department of the county
where___Ted.
loon OW-i North C.nmlinn Jkpnnment of linvirontncctal Quality_nivisutn oewater Ragaurcas Rwised 2 22-2016