GW1-2022-01110_Well Construction - GW1_20220107

Feb 1619 05:43p Clearwater Well Drilling 828-622-7241 p'1
WELL!ONSTRUCTION RECORD fGW-1) I
Fnr Internal Use Only:
1,Well Contractor Information:
,WATER ZONES
Well Connraaor Name rttoK Tn nHs Rrrmt4
ft.
tL
NC Well Cnntmctor Cettification Ntonber S.OUTER CASING for mat 8 eased wells OR LPIF.R Ira ieeble
imam M D1A R 'rL[CKNPBa MATERIAL
w fr, f6 in.
Camp my N laic 16.INNER CASING C!R 7lritIN1G thotmat stoned-lao
2.Well Constrnetion Permmit ft: �G I ZZ�7.,�1 PROM 110 1 aUMETEa THtCKN MATERIAL
i.l.r1 all nppiic»b!¢wr/lmn.rrrNcrlen pretniLr(1.r.1/1C County,Stair,Varin'to,err_) ft. ft. In.
3.WrN Ihic(chock well cue): R. ft. in.
Water Supply Well: 17.SCPJ&EN-
mom I TO D SLOTSm ICKNCSS I MA 6MAL
Agricultural nmunicipopubtic o n. t,- to
Crealtcnrtal(Heating/Conling Supply) Residential Water Supply(single) n• ft. io.
hidustrial/C,ommerciaT 9IResidential Water Supply(shared) 18 CROlf1
trri�ation "ROM TO MATERIAL s*fi,' C¢MC`ITa! DdcAtWUNT
Nnn Wnter Supply Wr.11: fl, & 1
Monitoring Recovery it. fa
injection Well.
Recharge QGrmmdwater Rerncdiatino ft. R.
19.SAtmickAVELPACK ita liable
.Aquifer Storage AndRerovcry &tlinityf3aaier tntOM TO MATERIAL t711TWCEMBNTMCIufan
AquiferTcst [.StannwaterDrainage n- n.
Experimentai Technology OSuhsidenec Comrot fL I n.
Geothermal(Closed Loop) [3Traccr 20.pR1LLING LAC tattachadditional ifneceysa
FR07rI TO DESCRiPT10N eolor. rgp/rorkr taMfite etc,
Ccothennal fHcatin oolin> Rearm) Odier ex lain under f121 Remarks) ft. tt
.f.DateWell(s)Completed:to Jqt A Well ID# tt. ft. t
Eta.Well Lor-9tion
R, l
1:trili y"0M.net),lsme .w+ V Facility(DO(ifanplicahle) n R• t�j° c 1..- t
345- GrnSS Cre.e k.bra.l ( , ill f�rino, R.
Physiral Arldress,City,and Zip �J _�-
R t
it.REMARKS
Count
Y Parcel Identification No.ON)
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iiatll richl,one 'gitst cM} p 1 (-1 ! Ce 'ficI o
8
w I Z (C� 2,1
6.Is(ur r)the well(s)OPermanent or OTemporary s' Maier f Cent rest Well Contractor Date
1 y ogning day.(uw,)hrnhv rrrtlf)>Mot die tw:lf(j mar(were)caanraaed in acwtdonce
i.1y Miss repair to an existing writ: Qves or g)No rr•irh 1SAV.."AC 02C.0100 or 1JA NC.AC 01C.'.0200 Well C�drrtn+nmu SlarrdmdF and that a
/;ib .n is i. -roir.fill Ina known weR 4 atunrcYion information am srpNin the:moure.griho teal.eflhft rcrrxrl hoc?rryr provlkd to r/w,wail rmmur.
nraoir under AN remark.scraon err on Me hurl;oflhb form. 23.Site diagram or additional well details:
St.For GeoprofirMPT or Closed-i onp Geothermal Wells having nce same )'ew may ux the back.of this page to provide additional well site details or well
exmsinictinn,only I G%ti'-1 is needed. hidieate TOTAL NUMBER orwclis construction details. You may also'attaeh additional pages if necessary.
drilled: ,.._.
�� �,(,1¢,j):ifQ,11j•id�TRLICTIONS
91 71•otat well depth below land surface: t Aft-) Zia. ror All Welis: Submit dti4 form within 30 days of completion of well
J%rr ruahiple n•ell r litr all d ntlu fdijferenr conshuction to the following:
I[►.Statie water Ievci below top of easing: S.IL.� (ft.) Division ofWater Resources,Information Processing Unit,
IJ'xnt,rlera!Is'elvivacaslnR,u.W •t"Q 1617 Mail Service Center,RaleigkPIC27699-1617
li.Dlorcholedlnmeter.� I U (in.j y11%For injection Welter In addition to sending the form to the address In 20
12 Welt cnastrnetldn method:_ above,also submit one copy of this form within 30 days of completion of well
1 C.au e-,tor, h l � construction to the following
11 try,a>Nlc,direct tsh,Etc,)
Ft)12 WATER St:l'P/Y WF.t.L3 ONLY: Division of W Ater Resources,Underground injection Comm]Program,
1636 Mail Service Center,Rateigh,NC 2709-1636
13s.Yield(gpm) Method of test: __ 24c,j/pr Water Supply&falectien Wells: in addition to sunding the form to
the addresses) above; also submit rate copy of this form within 30 days of
131),Disinfection type: Amount: wmptetion of well construction to the county health department of the county
where constructed.
Fonn CW.I North Camlinn Depanment of Iimirdnmcnt't1 Oaanty-Divisimt ovwater Roymtreas Revised 222-2016