GW1-2022-01113_Well Construction - GW1_20220107

Feb 1519 05Vp Clearwater Well Drilling 828-622-7241 PA
WELL CON§MCTION RECORA(GW-11 Fnr lntcmni Use 0111yc
I.S&'u-Contraelorinformation:
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Weil fbntradtx Name iL ft. 0119CRIPrION
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VC WellCnntractor Certification Number _15 QIrfERCA$ING ror %alt}aaedwells OR LINER ifa ticeble
PROM m DIAtNL7LR TtucxHPBs MATYMI"
ft )i OVL
Cn npnny Namc 16.INNER C 1NG OR Tt""NG tho mat Closed-too
2.Well Construction Permit#: �PRt)VI To DIAMETER TNICKNESS MATERIAL
i.Lrt al!nlyriicabfr well conernrnlon pxrrrtilr(l.c.t/IC,CPrsA7y SfnM,Yarlmca,art.)
ft. fL In.
n. in.
3.1VeH lice(check»ell use): f,
ter Supply well: �47.SCREEN
PROM TO DfAMETFSt SLOT9R.L THICKNESSMA1'&AfAL
gricultural Mdmicipolfthlic O f). ft. in.
. I I —+_
Geothermal(t•Ieating/Conling Supply) Residential Water Supply(single) R ft. in.
industrial/Commercial Residential Water Supply(shared) 1&CROU f
IRi^Orion FROM TO MATEAL zmrLACBMEWmr OD&Ar.T UNT
N 'n►tr RI 5uppiy rJ1'ell: tt" D 'L
h4onitoting Recovery fa ft_
injection Vi'cll:
fr.
Aquifer Recharge E3Groundwnter Remedialion ft,
19,SAND/GRAVEL PACK-En licable
:Aquifer Storage and Recovery Salinity Barrier FROM To mATERIAL fllfr CEMB TMETHADD
AquiterTcst DmrmwaterDrainage AL
Experimental Teelloology [3Subsidencr:control fi it•
BGcothennal(Closed Loop) [)Tracer 20.ORIIJ,ING LOG ailaeh alditionaldwts Ifntcesa
FROM TO DESCRIPTION color.harlots.wWrmk r M strr,srcJ
Geothcnnal(Hcatin Coolin> Realm) Other(explain under rs21 Rcmari s) te, tL
3.Date Wdl(s)Completed0A an-41 Well IDn 1 r�tr. (do it.
.Wet11_nt:Annn• VY'fr. ��5� � �•- _
Faci{itl:'(lnner)lam F ility iDit tfapplicA� � R, f4 n
rI(�'ylie(.�Ararcs,,city,and zip 2 13
rL R
J IL� Lot, ARKS
Co unry �a Parcel idemification No.(PiNiI
Sh.Latitude And longitude in degrees/minutes/seconds or decimal degrees:
(ii.wll fidd,o�t a iatgnng 16 SUifiClCTlt} o ,/ 7;14"'
lion:
6.Is(arc)tfie wells) Ptxmaaenr or ©iTempnrary
i ureni'Cenifial Well Contmetor Date
,vlFmilig dtlr.(t»n,1 harrhv(VII)fj:that the iwdl(a)nor(Wem)a,nrrrrnfed in accordance
i.Is this a repair to an existing well: E3Ycs orA."1207il
o v;tlr lSA.4r:'AG D2C..OlfIO or 15A,VCAC 02C.•.OIhD WeBCwmrlrurnan Stamlardi mat that a
/VII)h i.,a repair.,pll mrrknaKm rrtll.onsrrt+ctinn inrormaao+ The name.a(lhe aunt,aflhft record har helm prouder In't/u we"I nwner.
rrvoir raider 01 remarb-nrdmt oron iln:hark of rh6form. 23.Site diagram or additional we!It details:
9.Por GenprohefOPT or('.laced-Loup Geothermal Wells having the same 1'ou may use the back of this Rage to provide additional well site details or well
ennsiniction,only I GW-1 is needed. Guticate TOTAL_NUMBER construction details. You may also!attach additional pages if necessary.
drii M:­„_
-'--_--• � m1QIN17TA1,Il\STRiICaONS
9.INtal well depth holow land surface: _0h) 2,1.% I'or AIf wells: Submit this form ♦Tithin 30 days of coi"Iction of well
i%nr nmhiplc wra u,I wi depa",ifd+,�'arent(rtamolc-9C1!(r'olydsralnn1 cnnslnictiun to the following:
10.Static Water level below top of casing:� t1�i\1 (ft.) Division of Water Resources,Information Processiop Unit,
1%xnlrr icrd Is nhnve curing, t l 1617 Mail Service Center,Raleigh.NC 27649-1617
11.Borehole diameter: (in,j 24h.For infection wens: In addition to sending the form to die addrom in 24a
12.Well construction method: �QA014 above,also submit one copy of this form rvilhin 30 days of completion of Well
(i a aaga•,rotir%able,dirt PuIti,cm) construction to the following:
Division ofWater Resources,Underground injection Contra]Program,
rOR WATER SUPPi 'WELLS ONLY: 1636 Mail Service Cenmr,Ratcigk,NC 27699-1636
13s.Yield(Cpm) Ni fethod of test: 24c, liar Water SD dD y Bt faieeHon Wells: in addition to standing the form to
the address(es) above, also submit one copy of this form within 30 days of
13A.Disinfection type: Amount: completion of well cmutmcdon to the county health department of the county
where cnnstmcted.
I'onu CW.I North Camlinn ocpnnment of Fin.irdnmcctnl Quality-lws+nn of Water Rayaurcec i Revised 2 22-2016