GW1--06244_Well Construction - GW1_20241021

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This form can be used for stogie or multiple wells i[roe ia:etrai Use 0-cal:: f
1_Well Contractor information: L
Rex . e rlrr}4;et2 I•I4.TVATERZON•rS • i 1
Well Contractor Name ft. I it — _ —, i
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r:C i1ctt Connector Certification Nuntocr tc''aFl•: ++ir�rc=fi r,_: „i-::�r,,_,,_.VtE)ny_2 r-Tr_n•* _�kl
. Clearwater Welt ur{liina inc. ft E to
cgm�v�tartw - i ; I tt � T-f_ cV• I
I I.o'_INDIEc.CASING-OR TUBING(neuthernin/•used-loon) -- -.1t
»•ic a gi u`aii tri D ZZ `� D Z I FROM ' TO .. { DIAMETER n I TIICRNESS MATERIAL 1
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List all applicable well canstrucdon permits(i.e.Comity,Stare.Varinnee,erg.) i •» 1 "• ! 1 I I
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3.diteii 7Jcr+f_chnctwell use): I _.. ••
'-lgit;I r Stnira VAA: - -•[1 FROM [ TO 1 HLiMETF.R'1 SLOT SIZR i TIIIrKNIS.S I ,i_IATF-RitA.I. 1
1 ElAgricultural ❑Mtuticipaf/Public i 1 it fr.- I i ;a'i f !i
[a'�v'ev-SII%iiilal(i'iCuiiii�/Z.G3iiu uu t) �.� .. r_:_ • { r 1 :rt 1 ( 1
y Fi pp y) Awidcntiat��ate.r Supply(single) I i i i �1 i 4 i i
IOlydustrial/Commercial ❑Residential Water Supply(shaeed) II pd-. ouT -
n- I et.;ce.`.-::. : r.C..:^-i[i_lam' F=^L ^-G R-
I l�lrriRniilitt 11 .. .. 1 rt• 1T� I.. I._f/-,y/ l F l
I!'.ac-��atc.Supply Well: ' iI�t 1�'"---r--- --iC�t ,11C e`
JDtt ettit ring OReeever i i F, 1 _--
imJectiisaWeH Ft 1 fG i
i❑r:q:::f� zrse EIGI-euadw3;;r:::.a-.Ilattica I I n,o tcx=lc)_ !�
1 91;,�i ant-a -? ;:._� t•.:_ 2..�z I1 `•?art l TO �'-- mATERta,L EIDtFt-ACEMEIv:METHOD 1
UM-tiller Test -- Drainage
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DGaothe.rat(Closed Loop) DTrirer !I 'e t°r•,.`•era.`',`•>; °= =`"=_-=— `i= =:r„'"-`. - —___
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TO DESCRIPTION[ttirloi, ardoess,suNrack t}!iti atbio size,. i
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Sa.Weil Location:
a, Deior1shi r rs 31 i r i - _i
Fadli /Owlter Name -' 1 - ' i,_.... c�I--.,; ---' i f l
�ry Facilityli2r(Ifapplicable) --~( - -^ .... _ v-- p >i n�
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Them sin Rd , !
Yr:,=_i:vl It irlr ,-..it1,r r i(ip i _ _ I _ p-- 1 c02
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County Parcel Identification No.(PIN) I
1`3::r�(buncombe, ,
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Sit-Laiiintie anti Longitude in eegrces/irtivatesiaecrtmia or decimal d-hi-ees: _- I
(if well field,one la71ose is s ftcitc) 22.C:ertit'_atitln:
� 5' � •ads .. 32` �� i 5`l (n--�3�
r-i Siena o Cenifie Well C•nttactor Date
. Cr.if:,(-ace)C! ...4sr.C�): .tt-iL•f--ii[ii?, r1S Dr— r.7^5a^`y . _
4 e..�aa:z:..,AT..I he'rake cent•rit r.L_I.difi• c=•: rzr2i.cam.iruc,...:: '
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 1 ell Construction Standards and that a
't.as Qi:.5 a rei..o::;.'rot t<ts_-eistri.%---9)_•;;: D?o =; ki ccpy aphis re.cad m is.o ja4:•et.d<6:ha::ai1..a nu:-
phis is a repair,fill out known well construction information and explain the nature of the
repair ceder Of r_'iai-e_•__.:;:a or en the .-of tl:iijr_n?t 22.,.:,:a dies case cr aCt:` --! -a w pc,
Q_t�E:mhn of wells t-�tta 8^M�: .-. _.._ ca iJ •.• Jf: :.: ..
r: .. ••,•Jell
it canst>,iction details_ You may also attach adtiiti _al iiagrs ifrecr ssry.
For;-aitipl_itj_ctien orr:on-waersei••:4, ells%FL�si:3 the=a ----etfie••.;ettv..a 11
submitamjorra• SUBMITTAL INSiUCT1C5ia`3
4.Tlytec wdi dcinnt imiow in a5 ii _ 3 (it) _ t;; i� �$� -, er FOP multiple wells list oll depths ijdi,Jr_=.tea(,-oripk.I o 200•nod 2ia�100 r to .e.:o :r v f -'c `'r:c`� ���i
•C ') cou uu lion he following:
ill.Static water level below top of casing: -7 l 0 ((L i
} Division ui Jlater quanta),tram-- firon c-roc::c-ang unr,
jt_.ter l2:zi t:aba92 rosins;me--!-- I� 161.7 Me(i;rn-tee Ce;uter;RaTE:ft:,PNC 27699-1.Ct?7
I I.Borehole diameter.- IJ2 V (ha.) 2wb.For injection Wells: in addition to sendi ig the form to the address in 24a
f�„� 1 /7t ti g?_nsr_ nicri ^..her a arms_;:I a!=_c t":: r�inir _:i int•_ ri rna:ap;:nr. ---il
IL.Well consireelrnrt method: iI- IVl It�/Jl"/ `' c i�istrucn,7r,:h.ioli N r ' •- - - --
OF iiS o
�prgi r .Jet:;: :»:au.1tr.:a^- i'ilrcti.:p ---.-,::-on
[FOR V-i'_•�`r:!:SUU Lle'Lv'•:L_: .N - -
!- �r: i; SIT.Tit,ti2R:r der valt•i:Cirir:F,r4=i='a.a..•-���'!Ls>-,:.Jii
113a.Field(Spm) Method of test: �� i the =:: ,:_..�x_�__. a::�:4i___cl•«rl•.iy ..l.,. _ti, -=- -
1 address( ) above:, also<submit'brie copy if this forth within30 days of
;?-z;„•••it _---... --_— _._._ completion Ui well CU1ISUUCi10u: tU iilr:county It21111 deoutimeUI of tlh0 counts
ii:nrth r-a:pin,.t7.::nMni>nir.}-r,:,,, ,imnnv-ni sr,.i NSrnrat Or-
-I l,vicin:i At"L•'n=x r lliotiry H,..nc•,.i I :ti:1 .
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MI1 Maar Selliaahripet cerlentallow
ob1M. 00 6 NetwWell ,
haremI-11-VrrnPCL- Rgairt-
Pinsk; 2.1) 0 261•5'
I ime"essdateed wellwegtauted InIeLClft with •
0 CountrAtilides.
wed Dretev--ACX M-ea CI 0 CO 3
calfficatep,____fD11 3 7A Delt,areatea - •
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construed= - Grout "
Tone Depth;_a5
Casing TVs Theleses;-20—
Casing Deptix
DIRMeter: (.p
thwewaticut
Habott.„'
Drive•Shon; -
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