GW1-2021-03572_Well Construction - GW1_20210823

828-622-72,,41 P•1
Feb 151905,43p CleatwaterWeliDrilling
W EI.L COMM RECOR.ID f GyV-11 I or intcmni Use Only:
I.Well<Antmtor in oration: ^. -
`,� K WA EONE6 D89 lost
Well Catl"Clor blame fit
yG well i ell Illy�or�,C1e ttiifftolionn Numbs •$Qp 1 ER CAS1lVG Lisi1D1 a
lm.,an.Y C L c �Y �11 1 uaQat m rn� •tt t nu►\J
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crimpony,Warne i 6.ttVNBR CASINGOR:'PUSINC Hmraut
ll..�..,►�. yt QT�P1S67i 'PSICk'NeSS NATFNAL
2.Well Construction Permit#: TO It fi: in.
i,isi all npplicahle well cmwtrtrellon pwmits li,111C4,Ctratrly,59ate,Varlama,
tt. �• �-
3.1Yd1 itsc(cheek wdl use): 1ZSCRB1ilM TRIP CAL
Water SoppIl9Well: tgnont ro
Agricultural �Mimicipitl/pu6iic (j aR. tt. °"
Geftofflal(kieatingiCoal}ngSupply) residential Water Supply(single) 11.
ladusiriallcommerou+l DResidenrial waler Supply(shal 1s;.4=iff .� D&AtW001rr
ROM TO :ylA L SA7
lrrl Ition �.---- -- - n. O EL Q
Non-Water Supply WcIL-
monitol nRecovery
it. fc
Injection Well: n. ft.
Aquifer Recharge QGroundwatctlicmcdiatioa -its PAC to hfe
Rom TO
T< '. e>titrtncr.Ma TatacrltoQ
Aquifer Storage and Recovery° [3•Siilinity f3ntriea - n
Smnrnvlttcr Drailragia It„IL
Aquifer Test � --
" R.
Experlmental Techmlogy subsidence Control m
r0
Geothermal(Closed Loop) 13TcaccrDRILLING LOG adttteh �
PRO39
Geottietmal Kcatin Gail Return)( DOther(e%� ttttdcr#21 Remarks) ' it. fr
-A "WellIDY R� 1`
11 Oil
rnt<
A.Hate weti(A)Cpleted•
u Well Location-
1 n• I nD fR• t+�°`
L•Y °� M��issa F-4 P 111 f -
n.
I arilitls�OwnerN c - Facility Do(ifapplicahle) J
I � �reel� Pre exye 128 1&
P steal Address,City,and Zip
Q a5 38
Cimay Parcel Cdamif catitm Na.(PIN)
5h.Latitude nod!oagitade in degreesltnlauteslseconds or decimal degram
(it�o one lstgonl:in suitcicrtt} nI o .Ce t on
5o'4a.Di, Ja� �Qa � ��glo �� 30
ureefCertirmtWcl►CantmctarDolO
A.Is(are)the well(s) mneat or DITempornry , W,(weu eaa»acrA In actiardomeO Mtbixthrm.f hi-mhvrxmljymob uP .v 1N x arle 1S.t ti!'AC.'01.1.0100 or 1.fA,YCAC 02C.0100 Wrtl C11010w"'Srnndar&mn1 thin a
7.Is this a repair to an existing wail' Yes or IKP nnpv njrlrfr rsrnnl has ntrm pnitdderf la the wdi nwttrr.
Mtht,i<:,rc1wlr.,/tllnurknnwntu.:lf.:Onunvdnuri>tjnrmallonmrdrapraiirthenan:n n�rhu
rrrcir tinder 421 remnn@r.=I"nr(m ifla hurl'njthl a.(nmt. r�glm diagram or edditlonal tvel!detaiLv:
You may use ilte back or this Vega to',provide add;tionnl well stile derails or well
S.ftor GeoproheMPT or Closcd4Anp Geothermal Wells hawing the same ct)rAtnutioo details. You may also attach addlftimal pages if pmessaty.
csmslntction.only I GW-I is needed. fadicato TOTAL NUMBER Of—]Is
drillctl:�_."._ _ -----" W O� �A,(��I}'ol tm�Cl'R_ lam
?.Total well depot below land surface;
(D•) 2'In.For All Wells: Stthmit t)tis fLr»t lttithin 30 dtt,�s of completion of well
Far nwhiptc wells Usr at;deprhr jAf rrmu(exampk-101110'mad s�3t[ 1001 comtrurdiM 10 the f011tNvft:
10.Stolle wata•level booty tap of t9siag: (ft.) Divi16171�d SO co���R*I gh.WC276"_lfi?1fit,
1f xwtar rnsrr is rrhava caring•me"•"
I I.Rotzhoit diameter. (in•] Zgh.For iwf ctioa 3Eq tr io addition to sundials the form Io dil ttddfcaa in 74a
`m , �, ,• a--`� strove,obo submit one copy of this form wilbin 311 days of completion of well
17-f,Vell constraedom metbad: V Tt JLyI'( amsitttction to the fallowing:
(i C.mrae-,mmtwy.male,(fired pusb"Ac.) Div;slon ofVllster Reawreet.Underground Injection Contra]Program.
(n/I (� 1636 Mail Service Ceni Rateigb.NC 2709-1636
1�OR WATER gI pptY WELL ONLY'
13a.Yield(gran) 5 Method of test. `^ ` 11c. For Watar SnedY&llajlxtlott�_t i7 in addition to sanding the farm to
the address(es) abnve, also subrnu one copy of this rotor will 30 days OF
ci)api¢tion of.veil constgactian to the'com►ty hell deaatimenl of the county
1311 Disinfection type: —--- �1t0tmt' where constluemd.
t+ant C.W-t Alergt C hrofin I:)M tlaont.tt 1: .1t intagi l Cont y-Division of Water Rastnuees
Revined2-22 lot 6
I I

i
Date.
Well Case: Wellft ©off 01 4a3
Name: aa S fo btr M6'SSk PDY-
Address: sm e-
Pump has been installed, well head ready for inspection.
Sigh: X14 �--