GW1-2022-01092_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 p'1
WELL CONSTRUCTION RECOW}(GW-1) Fnr Intcmai Use Only:
1!C•on trite tar I ninrmatlon: I
C( T 14.WATER ZONES
Well CrnitmaLf Nalne rROK Tn DESCRttvT'ION
n.
V'Well Cnntragm CcttificAtinn NumherIlk iS.OUTFR CASING tormatti-ased welds tM LINER !fa ieeblt
VROM TO DIAIHET R 'rl iCKN S MATERIAL
tI, tt. "Via.
V�
Company Name. _
I&INNER CASING OR TUNING(Reathorato closed too
2.Well Construction Permit#: OM TO ounTET�R TRtCKNE9S NATERUL
iJO ali applicable well crmrinrctiott permits(Le.ING,,Cotmry,Slate,Variance,rie:) ft, k. in•
3•Wtll Ilse(check evil use): n, h. in.
Water supply well: 17.SCREEN
FROM TO
DIAMETL1t. SLOT SIZE T1rICIQIESS MATERIAL
Agricultural Monicipal/Pubiic O R. it. in.
Geothermal(Pleating/Cooling Supply) Residential Water Supply(single)
induslriallCommercial RlResidential Water Supply(shared) 1&GROUT
Irri^ation room TO MATERIAL EMPLACEME!ITat• ODBAMOt1NT
Non-ll'nter Supply Wril: f ri- 'q O (L t�
M
onitoring Recovery ft, ft.
Well:
ft. R.
Aquifer Recharge [3Croundwater Rcmcdialion I9.SANi1/GRAVEL PACK ire livable
Storage And Recovery DSaliuityBntrier _PROM TO 6fA lAL fltTILACEMEtVTMLT)tOo
Tcd []StnnnwaterDrainagoental Technology [)Subsidence Controlmal(Closed Loop) 13Truer 20.0I ll. LOG i t It additionaleheets feemmFROrrTDiMCRIMON rotor,huh tots mkt sate9W etc.mat(Hcatin aoliQttR Rnenp m) Uiber(explain under 021 Rern rks) rt fr. aAW l r'Y.'
d.!late ulell(s)Completed.•-t-Ol___ V Well iDY �i
Su.Well T.acnNnnC�h i I IIS N QI4 ft ( a Q' ,
I actilih;'(1„a, 1]amc Futility lt)ri(,f pltcahle) n' _
5� l I" w
Physical Address, it ,and 7fp r 1c FL R N
n 0 so ' t v 2l. MARKS
C'i101v�tY `a Parcel idewifiention No.(PIN!
ih.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(ifW011 Gield,one latUng is/sniTeictd) o o '22 C tiflcntion:
3.31
6.1s(arc)the welt(s)i_3@Permanent or ©!Temporary m urcnfcenifa)wellCcmtraaor Dale
TT''�� 16v M mist;i1j1.e,(%vm,I herrhv ewlifi:/hat der twdl(s)was/wars)cwtvirn yed Ht ocmrdonce
7.i:4 this it repair to an existing well: Elves or
r-ith I SA.St'AC a2C.?fO1J or 15,4 3C.AC 02C.0200 Wr.N Conrtmrrion Siaadorda and Am if
li'tldr i,a rcirair.fill met kmwn xvll r!0aanrciian irt(armada on crplain the nature oftha enpre nfihfc reeved haehem protf"10 rite we11 envier.
mwir under 01 remarin,xrtlan or rrx the hark afthla fomi.
23.Site diagram or additional well details:
A.Far Gemprobe/l1PT or Closed-Loop Geothermal Wells having the same Vou may use the back of this page to provide additional well site derails ur well
oenstniction,only I GVd•i is needed. Indicate TOTAL NUMBER of wclls construction details. You may also attach additional pages ifnaeessary,
drilled:
_____..._..+.,_- --... �TIQiNiTTAT,[ASTRLI(;�,7QNS
9.)fatal well depth below land surface: ,(R) yla, For AIL WNLc: Submit this form within 30 days of completion of well
Farmnhiplewr0slivand,PN.cjdiffrerrreromple-3(n,2110'and2@1001 construction to the following;
10,Static Water1cv4l below top of casing: O (rt.) Division of Woter Resources,Information Processing Unit,
1/'nwlcrlv�e.lserlvevdtming,I","r•n^ 1 1617 Mail Service Cen ter,Raleigh.NC 27499-1617
I L Borehole diameter. lX 1� ((iin.)� 24h•For injection Wells: Its addition to sending the form to the address in 248
12,Well coastniclion method! 1 U (,(.111/I above,also submit one copy of this form within 30 days of CompIcUon of well
0 C.au e•,m, construction to the following:
Aug a-, try.a'dik,dirtt't intsd,c•{c.)
FOR WATER at,PPI Y WELL 3 ONLY: Division of Water Resources,Underground Injection Control Program,
f 1636 Mail Service Center,Raleigh,NC 27ti99-t636
13a.Yield(gpm) r Method o£test: 2:1c, For Wstcr Sunniv&faleellon Wells: In addition to vending the form to
n the address(cs) above also submit one copy of this form within 30 days of
13b.Disinfectlan type:, Amount: completion of wdl construction to the corny health department of the county
where constructed.
Won Cw-I Norlh C"linn Depnnment of rin%irdnmcntnl pnatity-Divisenn oP Water Raeanreee Revised 2-22-2a16