GW1-2022-01111_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 PA
WELL QNSTRUCTION RECORD(Got-l) For lntcrnai Use Only:
t,Wcll .nnRaetor inf a ion: ���
14,WATER ZONES -
LVell Ctnttragtx Name im " Tn DEs[a[Ft7oN
�l�/'��t /�
VC Well Contragot Certification Ntnnher S.01 ER CASING for mot&med wefts OR LIVER V a e
�r t+80rt M Dt GR [ NR9 tr►L
ft. f1. in.
Co;npnny N;tmc 1A on
t 6.INNER CASING OR IYG titartaat cles4d4coul
2.Well Construction Permit#: ratttat TO otAMLrER TA[ s MATERIAL
i.lr1 rrli mpplivable well a monrctlmm parmax ae.10 Conaly,Slalq Yarfance,etc.) ft. (t. In.
3.1Yell Ilse(Cheep wdl use): ft. R'
Water Supply We►i. �ras N
FROM I To DIAMETtS2 SLOT 9t7.6 ICKn6MS MATMAL
Asriculturs! MtmicipavPublic l? R. tt. in.
GeaherRW(tieating/Cooling Supply) Residential Water Supply(single) tt, tL in.
tndustriat/Cottirrtercial Residential WatcrSupply(share!) I&GROUT
I171'+atiOn FROM TO MATERIAL 9MnACEMV.F34 0D&Alt[OUNr
?Yon-WnttrSuppl_y Will- tr• fc
[hono., Recovery tt. rr.
n -
fl. R.
er Recharrc QCroundwater Remediatinn
erStorage Md Recovery [3salinity i3anier 19,o3MQ71l/GkTn11EL PAGK 6A liable FJtR[ACEItIBrTst QStorhwaterDrainagemental Technology (3Suhsidencc Coinrotermal(C:losed loop) 0Tracat 20.DRILLING LOG ttttaRROM TO DE5 N roW.hartlam,aaWmk . rainshee.et,.)
ermat(Beetle oolittE Rentm) Uther(ex lain tinder R21 Rcmttrics)
d.i)ate{Vdt(s)Completed: ;Z�Well lDtl rt. Wrt- `�^�i _
3a. elll.nrstlnn; 1.
F:tcilih:rrlemer Hmne I Facility[Di!(ifapplicahle) R It. 1 7
Phyii,-i(Aed-,es Ciq,,and zip / ctC`�Y►�"� ' s s r t {e4
21."MARKS r ati tt;'i.
t^auntY Paget rdentitleation No.(PiNi
Sh.Latitude and longitude,in degrees/minutes/secoads or decimal degrees:
6'well rreld,one 130ang is auirtclent) d 1 t( 1,12.Certl a n:
b.Is(arc)the well(s)1Pcrmanent or 13Trmporary sign e n .enirttvi well cantmetor, Date
L,v signing this j rep,J hrrrhy rrtrih:that the ndl(a)wai 0wMN1 exorwmered in acwtAance
7.1s this a repair toan existing well: E)VoS or No with11f.'-CACVC.0100ar1SA,YCACMC.0200 Well Cfnsrn,ntnrSlandardr and chata
di is:>repafe,f/lrnukneamnel/mxsuiviraimOformalimYarol`crplmnthenan,renrthe topprif/hfrreelw1 ralbrenpmLldedtothewei'la ter.
r•;aair tinder 01 remarlcr.rtednm nrna lln hark ojlhis jomr.
23.Site diagram or additional tcc11 details:
R.For GcttprohelOPT or CJmed-Lonp Geothermal Wells having the same Vou may use fete back.of this page to provide additional well site details ur well
Wnctruction,only I GW1 is needed. indicate TOTAI.NUMBER or%-miis construction details. You may also Attach additional pages if necessary.
drilled:_. ...._._ � qO
9.Total well depth below land surface: _(R•l 24% IFor All Wells: Submit Otis fort within 30 days of complMon of well
1%rrlmalt!plcwrlltrivet�d.rrlte�di�ercnt(rrmnnlc-3(1?U(r'omis�nlln0� consm(ionto the following:
10-Stafre water level below tap of easing:,r (it.) Division of Water Resources,Information Processing i)nit,
I f ralvr Am!!is#bmra cndng,uaC '•�' 1617 Hall Service Center,Raleigh,NC 276"-1617
Ii.Borehole diameter: I � (in.j 24h.For lalection Wells: In addition to sending the form to die address in 24a
12,Well constrnetlon method: above,also submit one copy of chit;form Lvilhin 30 days of completion of well
(i a mtger,minty.cable,4iretq pttsb,etc,)
construction to the following:
Division of Water Resources.Underground Injection Control Program,
FOR WATER 9t;PP1_V WF.i.LS ONLY: n r 1636 Mail Service Center,RAtelgh,NC 27600.1636
IX Yield(gpm) Xlethad of test• 24e. her Water Sued►A Jarce on Weilr. In addition to sanding the faro to
the addresses) above; also submit one copy of this fort within 30 days of
13b,Disinfection type: Amount: completion of.yell construction to!,thc county health department of the county
where constructed.
learnt C\4'-I Noah ca munn tacpnrnnent of Itn.ir6nmenrnl QrtaEty•Division of Water lLeyaurces Revised 2 22-2016