GW1-2022-01118_Well Construction - GW1_20220107

Feb 1519 05:43p Clearwater Well Drilling 828-622-7241 p'1
WE .L CU�tS7'R1kJCTION x2E99I?A(GW-1) Far Internal Use only:
I.Well C.on tractor Information:
©St 1 PU t Y t t®n,S 14 WAUR ZONES �Well Ceninclet Mahe -in DESCRtPr10N
iL R.
tt
V(:WppellCnntranorCeRiBeationPhnnlKr A q .OUTF.RCASING(for mat11s1isadtvelh Olt LiNER Ifa e
i'c] DIA Tt[ E88 MATERIAL
CampnnyName VV�iCi[ r 1 ft i fL r. L in. V C
1 ^� 16.INNER CA$I OR TURiNG tlroemal etaaeit400
2.Weli Construction permit#: ��� .� � (Q�S OM I TO I o"Mt[F11 rnrcwtvEss MAtEwAa
i'10 all o/ydicable'Ved eenrtmetlon parmila(Lk tl1C,Cntrrtly,Stale,t•:rrianrc,eta R• k• in.
3.INAl life(Check well list):
Wa ter Supply well: �17.&CRBEN
t�lsl'ICUlhlfal FROM TO DIA TE�t SLOT 91t6 TRICOMMS MA IMIAL
MunicipaVPuhlic I) ft. ft.
Geothermal(Heatittg(Cooling Supply) Residential Water Supply(single) R iL in.
[ndwilrial/C.ommercial Residential Water Supply(shared) t8 GRdIIf
Ittiaati0n FROM TO CML1. rr
Nort%Vnter Supply Well: rr 0 rt• G -
R4onitorit►g Recovery tt. ft.
injection well:
!1. R.
Aquifer Recbetge QQroundwotcr Remedialion 19.SANiIiCRAVfiL PACK lie i Me
Aquifer Storage and Recovery DS dinity Barrier FROM I To MATERIAL tPLACEMBnT MLTH00
Aquifer Test []Stnnnwater Drainage R n•
Lxperimental Technology OSulisidence Control fL tr.
RGeothermal(Closed Loop) 13Tralu 20.DRUM,NC LOG tellsch additionst fneonsa
Geothennal(Hestia oo[in Rcwm)__\\++ ()Iher{explain under#21 R FROM TO 01aTRHTMCOlar.hnraaess,saivrorR frain site.etc.)cmarl:s}
t,Dete Welf(s)Completed: P 1 well tDt1 � n'-Z �.L( _ it. 0tL 1`
Su.Well Location -]^[�ft
C� wic R. 4 n. arlfVk V-`,_�
I:ici{ih:'(ta„crltamc Fa ilitytDil(ifopplic;tMe) a (L
(7 0(le{2-j/
Phy irnf A dracs,City,and Zip (/ 1�1
I/D L(( 2i.REMARKS
County Pareel fdcncification No./PiN)
51).i,atitude and longitude in degrees/minutes/secondsor decimal degrees: -
(it well fieldbone laMong is sulTicicnt) p p :i2.lc fiention:
n go.gg N ORI Qa �� W a
6.Nam)the well(s) Permanent or ©ITt mporar'y Shin tire afCertiricd Well Ctmtraetor Date
1; .rtlmiag dio P)m,I herrhr cwtifj+thai'lhr nvddl(l)was(wars)t.7a+drllWed in aemrdoncr
7.iti this a repair to an existing well: QYes or No x•irh i.SA.tr."AC'02C.0100 or 15A NCAC VX.0100 Well Ce firtnrchan Slandmds mil that a
;t flur i.�v rrlrair..fiN autkrMwn uv!/,oaarncrian i>(fnr naliana n crplain lhr.ncaurc q(fhc tap.p afllift rived Mr been prsil"In rite w411 riwlier.
raw under A71 remarks scalar ar rM Flu:hack of Ihn.(nmt,
23,.fife diagram or additional well details:
R.For GeoprohetOPT or Closed-i anp Geothermal Wells having the same Vou may use flit tack of this page to provide additional well site deals or well
conslniction,only I GW-I is needed. fridicate TOTAL NUMBER of-wrils construction details. You may also attach additional pages if necessary.
driliul: - -((j
_. _ �I i S R, �'UB AT.iNKIFRLiMQNS
9,Total well depth below land surface: �( ) 2,h. for Alt W-A : Submit this form within 30 days of cen"Iction of well
Far nruliip/c•xrllc li4e Wideptle ifdifferenf(rtampk-7 o.Sl/O•an%%d�r enneuttction to the following:
to.Statie watrr level below top of easing: 0 �� (ft.) Division of Water Resources,Information Processing Unit,
ifwale)•leve.IyahoreC-Ming•Me'
(••IP I�( 1617Maiil Service Center,Raleigh,MC27699-i617
11.POM110le dinmetet•: lJ (in.) lib.For 11lieyion Welts: In addition to Sending the form to the addrm in 24a
IZ Well eoustrnenon method• h7 aAU a1mve,also submit one copy of this forth within 30 days of complalon of well
tic.ail e:,ro, cnnstmetion to the foilowring:
g tvp,cable,direct plash,cxc,)
Division ofWater Resources,Underground Injection Central Program,
E, ,
Sf,PPLli wELLS ONLY: 1636 Mail Service Ccater,Ratetg6,NC 27b99-1636
tn) _ Method of test: 24ic.,For Witter SoPlAy d faieetlon Welts: In addition to sending the form to
the address(es) abovq also submit one copy of this foal within 30 days of
on type:,w•_�� ,Amount: camptction of well construction to the county health department of the county
whore constructed.
lc+snn CVJ-1 Noah Carolina 1)cpnnment of tin•ircinmrneat Quality-Division of Water Rosourcea Re:vued 2-222016