GW1-2022-09749_Well Construction - GW1_20221027

828.622 7241 p.1
Feb 151905'.43p Clearwatel-WellDrilling •• •-•�µ,•�
WEkL CONSTRUCTION RECORD{GW-11 For inlCM F Ilse Only:
!. r11C.nntrae('tvnrllnfoem�atF�onJ• 1
In" 1 Vl�,t O w� 14,WA ZONES DB9t RtlrrON
t+Rox To
Well Contragor Name re �•
YC:Wc11 Cnntragvr Catlfication Num1Rr `` �, ly is.OMER CASING tOr tttatti•e+red vvelBt OIL Li?lER ® t
URUM To DlAME7LiG ttl[CKNP83 MA IAL
f1.
CospnnuNamc �16.pVIIER CtL81NGt2RT1tSING Idtasmatcitae0 ioo
irRt)M To DIAMErEA. TA L
ICIQ�IPSS NAtFA1A
2-Well Comatructian Pertait#: ft• fL M•
List all apidicabie well eonrtnrdian permits(I.e 10C,Caanty,Stall;Ir4r fle,'14)
n, k im
3.tYe]l 1L9c(check well ust)c
17.SCRBStV DfAMB•rEtt 61 TgICMjMS MATMIAL
Water Supply Well. FROM Tn
Agriculturist MltmicipallPublic () tr• - in,t reahrrmat.Supply) Residential WaterSupplg(singtq) M tv in.
IndustriallCommercial 13Residentiat Water Supply(shared) 18 Ui1T
lTlit)li'I qp MATERIA - EMM1,C6(11E•rTNnTR D&AAiOtIN'c
Non\t<'alt:rSuppl_yWill- �r
AQanitoring Recovery tl, fr.
Injection well: ft. R
AquiferRccbeTge MGroundwaterRentediatinn 19.SA1VplGR+IVELBACK(ILUBMACMpir
Aquifer Storage and Rcroverg rlwnity Decrier FROM TO MA L E11t►LACEMn,�HOD
Aquifer Tcst 13Storinwatcr Drainage
r Experimental Technology oSubsidence Control R• R
t'.reothetmal(Closed Loop) 137facer 20.DRIi.L1NGLt1G attachrarl nlafi ittttxta+earv)
OPSCATPItOi'l mlor. rcp/roeri ram rtsgetu
PROW
Ceothcnml(Hca6n Cooling Retum) Other(ex lain under d21 Remarks)
A.DateW1ell(s)Corte feted: L v ���Well IAB , R. op iL
Al.Well T.neallonaj�{t�(Y)� ('n r r [L tV n• l w' tt '"-
A r ft. �ZS
Y:�rilit}:'Clnncr?tame 0 Finality loll(ifappliwibie) — -
Paysiear nrhlress,ciry,and zip � • �
REMARKS
Conroy PAVAlfdcntHicatian NO-IPM)
Sb.(Latitude nod lonpotude in degrms/minutesfsecondsordcchmnl degrees:
(if%vz�ell 0011,an;laaftminCsullicicnt) o i f /p ;2.,Ce i finis: 1
`sue`""D kcr I J �./L
6.ls(art)the wells) Permnuent or ©ITeaTpn ary Sign tore ofC�tificd Well Camraaor e
Ru s$mutg ddR,;arw.i hPwhy rM1f:that the wdl{x)win 1•Srcr•)umwPu Md Nr acvatrtance
7.1n Reis a rrpalriu an cxisdpg wcri Dees or MNQ o rrh iSA tiC`A4 D2C.#too or 15A NCAf.02C.'.f1I11D Well Cnrulrnerivn lyandnrda rm�!rhm.r
!J'd,(r;c:rrrpair.,�Mourknawniwll.aaamcttaair{lncnus(im�t�iu`Frrpfainthe nnmran(dm capj,oflh!.Qrrrard Aar been pmM4&dID the Well mvtkr.
r•:�a1runder R2!remarkrsrzttnu nrnnthcReel nlIhivlornr' 23_Site diagram or DddIdO tat WWIdetmils:
R.For Gcoprobe/I1PT or Closed-l.onp Geothermal Wells having the same 1'ou may use the back of this page to provide addilionui well S(te demilA or well
rxmsmrction,only I GW I is needed. 1'ndicate TOTAL NUMM of�vcllA cntl9tntcticsn rlctails. You may RhSt)attach additional pages if necessary.
drilled- ___ �,I M1'M ONMIRtJt'RO1V_& -
9.,Aotal welt deptfi lrclmr land surface-. 3�' - (&) 24a. rF'or An Welk: Submit thin form within 10 days of comldeljon of well
l�artuulriplrw•ell,Ntr all drpdrrrjrr errtn((sannle-3(nISUR-artd�t+r lOr►� tip tjpnt[)ttlefOl1614'111g�
III.StRtie waterlevel below top of casing: (ft.) DFvlriDn of Water Remraes,Information Processing UP%
!f w•aler•Anel is ahays rraiag,Free"• 1617 AlAll Service Center,Raleigh,NC 27699-1617
11-Borebolc diameter: "� / (Ia•) M.Vol:11liec'op In addition to tending the form W d16 addrens in 24a
above,also submit one copy of this form within 30 days of comPle OD of Well
12.Welt construction method: T crromtruetian to the followirC
(i c,mrg�,mmr).cable,dircctpusb,cYc.)
Division ofW ater Resources,Underground Injection Control Program.
MR WATER 6tPPLY/WqE�LL 9 ONLY: 1636[Nail Service Ceo=r Raleigh,NC 2.7699-1636
13a.Yield(gpm) ![� l4Cthod of te9e >�� 2rte,ltnr water Rnndy&iaFecHmn Wells In addilicn to sunding the(b M to
the addresses) above; also submit one copy of 09 form within 30 ditys of
tab.lltsinfcetian type: _ Amount: completion of tivcll construction to.tho county health dcpnnmenl of the county
where omtnteied.
Form GU*.I Nordr CAMlianDcFanmentoft:n ironmcutal O,uality-Aivrsran of water Rcnaureca Re�isat 2 22 2a16