GW1--00695_Well Construction - GW1_20240125

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Feb 1619 05;43p Clearwater Wall Drilling - 828-822-7241 .l p,1
33 JL c9NFIRIjcirkON RECORD(GW X) ( '.�...
For intdxnnl Use Only:
I•Well Mr information:
O. S _14,WATER ZONES
Well(:Cp{y�Name - moss TO 1189SfUMrrON I ""'�� .
:,IC WettContractorCettification Number ;G a. I.
/e// ' ' LE onom1TERCAf�SiNG(fartatDTA ) wells OThl MESS MMAT
(` / OC� /// R 7711CK1Y8BS MACF�t1AL
Company Name �j 7 !JJ� ib m i5x�r in.. I pve
z.1Ycl1 Construction Pernik#i.Z ICJ —y 7`g 79 f3� W1'fER f:A811tIG 4R 71i lIAMG(geothbrw,l elemal toap) V
M 7rD otaut tEn TRICtat= MATERIAL
/in all applimMr e�Hrnuentenim parmia(1.0.ING Cama
y.State,YuWrmcr,eta) O. ft. I in, I
3.Weil Use(check well use): - fr.. e ; in I
Water Supply Well: = i17. f
I AgriculturalaniafpotlPlibiic m+ re
IMP SLOTST TRicsOnesS reffsuar.
tf 6. fw
Geothermal(T3eatiny/Coclhrg Supply) evidentlal Water Supply(single) • p . fi. in. I
Industrial/Commercial faReaidenrial Wafer Supply(shared) '
Irrigation -�8.G1#OU? - . I
aOM 70 MATERIAL� riJ►CBk1C.�EMOTr/0D&AI OUNT
Nan ItnrerSupplyWride ! rt.
OW tt.. Z rylK lf-- rn' '0 ci7
Monitoring g f
Rccovery ,
Injection Welk , .
tr i.
R.Aquifer Recharge
�t3ronndwitter Remediatinn �.
Aquifer stomp and Etecnvc S.dini Battier T-9 SANiI1GRAVEL PAC (lfnpntlabk) I
ty intuit TO MA1ti1R1AE. f PMPWCEMBNTMETItOn
Aquifer Test ri5tnnmvatcrDridnngc H n. n. •
Experimental Technology ology DSubsidenee Control ft. ft. I
Geothermal(Closed Loop) jTtacer xR DRILLING LOG(Miaehaddition:she rift i emers2
t3eadiermal(iicotin�CaolinskRet+taa) Ottrerfexplainendorlg2l Remarks) PROM TO o Ntottor.Itatt u�.owroektrpe,gaineine.ma
4.Daft WON)Completed;p iq Y 013 Well DU /0/ fw <ro •
Sa.Well Larjidnn: t f©/ II' �r%Z h ;y,~/ j�l' &v a
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L J�...., 6 ys LL 6 _�oz ft. it 9'
i scili$:'(1atter}lama . Facility Wit fiflmplicnble) it. R.
• ..LZ ( &-.s /J)5 e fri is I I
• Pit ataddresa,cis},,one zip ft. a. _.—'"
detSon atJ>aMARK7C �:,. -.f.t, - ) _
County Panel Ramification Na.(PIN) ! J l'.^! 2024 5b.Latitude and longitude in degrees/mlirnteslseconds or decimal degrees: - •
(iiwelifreld.one Wong innuimoicra) ;2.Certircatio ln(NI?rF(,r ! .t..v;ng UFA
35' �q: ID N is .qq �a7,za w D't.0130G /-,, _7_cg3
6.h(arc)the well(B) j crmanemr or �ITempnrary Sipnme f fiktt ral Well Contractor Dale
7.it this a repair Air Ow OW(brat,1lattehvrwtrfr that thr wept)a►r Ovate)consattml in asnoritame
l7.lis pair to Well: f)Ycs ar No 1SA4CACO2C.0100or1SANCAC.f12C'.0200 WellCjnmvoiaaSYatrdopdroars!ha!a
repair,fill mrtlonnun null&lax:roathat i tc nnniion adr air the namn nfthe en ynfiltlereeord 110.01,tl Pr0v(dg/f*thew&owner.
repair under A21 ram*soct/mi aroeilie Back of tbixform
23.Site diagram or additional well dentine:
8.For Geopraht/pp•r or Cittaed$.tinp Geothermal Wefts having the some Von may use die back of the:page ta provide additional well Alin details or well
commotion.only I GW.1 is needed. rndicato TOTAL NUMBER orwclta coriatruclinn details. You may also tent te:addllio I pages lfse eessary.
drilled: -_ I;
/Q� - InMiPi' a Ittia'173ttt zum
9.Total well depth below land aarfaec. 0
Conan
Pal nrullpplc wells 1pxra/1dynJ„r if.(crcnr(r.rwf ht-3 ntn?70(t'aat!c�i laA'1 MT •Yor Ail Welk: Submit this idiot within La
O das of completion of well •
t11M to the ibllowing:.10,Static wotr'Icvel below top ormaing: (ft) Division otWater Resourcv.,Fnihrma Processin Unit,
IIfwaterrem'ihmcaing In ." O !;
U/
/n t 161711iail Service Center;Rettig AIC274f9 -i6I7
iI.Roreholudtameter. iEr. 00
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L 2eb.For fli f eel;a_Wjllw To addhion to sending the foam to the address in 24a
12.Wed metric lion method: ro`G��'l� above.also submit one copy of this form within days of completion of well
(i e.rune.rotary.cable,direct push,etc) construction to the following: I
F�On WATER SUPPLY WF.LLS•t)NLY: - Division ofWater Reatlilroet;Underground t action Central Program,
1ft36 Midi Service Center,Raleigh,NC lG36
13a.Yield 8D
IlAmi Method of test: 24e.(tor VI/Dior Sunnily&tendon WAD: la addition to sunning the Corm to
the addraas(es) above, also submit one 1copy of'this form Rein 30 days of
rah Disirttectkin type- Amount: completion of well construction to the county health deportment of the county
�' where constmeted.
Form GW-t
North Cemlion Department ofiinvlydnmcaui Quanty-Aiulnnnof Water remora= Relined 2 22 2016

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