GW1-2021-03689_Well Construction - GW1_20210823

Feb 1519 05;43p Clearwater Well Drilling 828-622-7241 p,1
Vt'EX.L 1COS�1S; i1;7 TIO1V I2EC0Rri, MA-4) Fir Inimal Use Only:
I.Wet CoaInetar Information: I
ZONES
►WclI Contractor Nknr}a icons zn
. a. .,.�._7 .....,....._.. ft. 0.
VC Well CAntraaor Cextifieation Ntrmbe IR ptT1'E)t CASING tier m- aced' tiRLI aIER !i !
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CAtntraoyName {
II µlb.tNtVBR CASINt:CAR 1MM D t'rIIl THICIMM MAT ALNU 3.Will Construction permit#: („� at
"'0 all nl frlicahla'w"I canrinrctlon pmmils(l.tt M .,Cana/y,Ma/q Yarrrmrc,Cie-) f!• k. tn•
3.wril Uir(check well list):
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Supply Well: t7. N
FROM 4 ro n TNtC Bus MATERIAL
culhiratMtmicipal/Puhkic
hermal(Heating/Cooling Supply) MResidential Water Supply(single) (L fr, in
striallcommercial ORt sidentiat Water Suppler(shared) 18.C.RQI17
ation T MAslca L tiMeLAe; YT]I OD AnrowNT
nrcr supply V/nll: fl. JGitoring Recoveryon Well:fer RecheW E3(•rroundwater Remedistionf9 AVELPACK bleferStitrageandRecovery Osnlinityannier -7pM Tp M AL BAtRtfcrTest C)StormwawtDrainage (L Ar.
rimental fcchnnlogy [3Subsidenee Control IL a.
hermal(Closed Loop) OTfA= r►1111 Lt3C Mat& dtien»nritimtm aoii Rautmt t}tber( lain widerP21 Remarks) �rx - emar. ef<hei rr�r.ae.
!.#lase k'ell(s)Completed.- • -�well IDl1 t fr. � ;r IL � `"Alf
t l
.ria.Weil l nesetton: D)"'�Pw luc ij
r eel{ijtyYkx )Iarnc Facility too(if.VPlicnitie) n
Physiraf Address,Ci Pand 7.rp S tt. IL
Canntp NMI Identification No.(PIN) �D#tiff 3,G�
Nb-Latitude and lonAllude in degrwiminnteslseconds or decimal degrera
(ii%veal field,ant lntgang is suiricic t)
t: t "2te flrAtfon:
6.ts(are)the wtit(sj Ptrtnanent or DTearlmrnry Si" i—ac of Omnirwd Well Canuactor not
,tv mpwia$rhw rrm,I henAv newt(*that Fhc n JI(A)teas t(wv)arrrcrtr wow Hr acrardwrcc
7.!s this a repair to an existing web: Elves or 1Vo Rirb 1 Lt 4r At'D2C.?lp0 or fSA NCAC.;O?C,'.8100 A'r1J Cuaslrnctirnr 3rorrdardr and Am a
;%"drat is a rcirair fin rnrakrteam nvll,rurrrinirtina itfjarvnrAhra m rrplpin the rxttrrrr lit/he ¢»lit:afth!s trrvurt has h*.ar pra1"!1f to rl stud/mmCr.
r1wir render AN mmmkc,%merlin aremlln?hark of/ldxfomr.
23 Gite ttiagrtttn or rldtNtlolml well 1mltRa:
8.1%or GeoprahrA)PT or Clltoed-I euutp Geothermal WON having the same bolt may use the back of this page to provide additional well site details or well
COM rtirlian,onb.1 Ghr-1 is needed. Indicate T(YfAL NUMBER of%wcllc construction details. You may also attach additional pages if noewary
drilled-__ _. �� s�tt¢IwiTTnr.,i1r,,TRtrt�rcolvs
"'. •atat Well lY below land surface; (R�) 2 11. 1'er All Wells: Submit this form within 30 days of compialion of well
Frrarrrlti rrrfe aro/!.)-s/l MY arldeprAcrifr!r„QFrenr frxampla-3(dlldfl`and�lptl9
crtnsfitctitm to the following:i(l.±Retie Water level betaw top of Iasi ogr R
V'q,aler!avv:!04`0ve c7rring.RAC"•" { ) Divisloa of Water Reauuree%information Processing Unit,
t)latrholydiametere �- (t 161T Mail Service Center,Raleigh,T1C276"-1617
s (In.) 24h,For 1xiectiaa Well iw addition to sending the farm to the address in 24n
12.Well constroctlort method: IL.'A ail l above,also submit one copy of this form within 30 days of completicm of well
0 C.angc,mtytl•.G7ble,4irect push,etc.) � I construction to the fallowing
1'DR WATER St:PPJ V WELG4 tlIVLY; Divislon ofWatter Rennurcelt.Underground Injection Control Program,
106 Mail Swwee Car ver,ttaletgh,T(C 77096•1636
13a.V.
(Rp+el Method of test,_ i 21G IfQr liter CanMy&FRkctlott V►4ttr in addition to sending the farm to
the address(cs) above, also submit one COPY of this fait within 30 days of
rah.01sinfection type: ,Amonah eomptetion of Well ts}rrstarCtiOn to the county health depattmcm of the:vounty
where Constmew.
1 awn GW.i North Cara"n t rk!'Aament of lieviraamcwnr i:Qantity-taivisran at'1i+attr rtagoorsac
Rrvised2 22-Yaib

Well Driller Self-Grout Certification
^1--
Owner n..'Edi MC'Li- 1Y U01) New Well: `
Address: E i CL-t Repair-,
Permit: I l:�1 i
I hereby certify that the above referenced well was grouted in appearance,in accordance with
all County Well rules.
Well Driller `�� t'G`iC C�v S Signed:l
Certificate#: Date Grouted-
Construction: Grout:
Total Depth: �; -_i1'�L ni-
T.vle:- W C Thiclaness: d
Casing Depth: 7�' Depth.*
�U
Diameter: !S/ ' I S"
Weight/Thick
Height:
Drive Shoe:
GPM: ;-
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