GW1-2021-03905_Well Construction - GW1_20210823

------ — 828-622-7241 p,1
Feb 1519 05;43p Clearwater Well Drilling
WELL CONSTRTJ pir 90—R-1 W�"11 Fnr]nlcmnl Llsc Only;
t.Weltr.nntrrte(nr Information:
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Well C:otnrauor Name ft.
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4C Well C intraclor Certification Number is.OU I ER CAfiINiC OtA1NLT6R� tDR t�ttt a MAC!!/M31'
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I.Well Cotritrnetion Pen tilt#: ft. f
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3.Well Ilse(check well list:):
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Water Supply Well: — ;n
Agricultural
MunicipaUPubkic (} 0. ft.
Cleothetmal(1•Ieating/Cooling Supply) aResidential Water Supply(single) M
industrial/Commercial Residential Water Supply(shawl) igp
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MA•r);RrAL rCMM{/y p.AC `R?1 ODd,AMTOt1NT
KitDtl
Irrigation 0 fu 20 IL r f t(;t,
Non lVoter%upplyWrill-
T4onitoring Recovery
Injc"'*n Well: ft. It.
Aquifct•Rechurge �CronndwntcrRcmcdiatinn t 19 AtJDJGR+�VBLPACK Ea hie d aNT1WrHon
:aquifer Storage and Recovery asafinity Barrier DIX Tn A L
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Aquifer Tcst OStnrntwater Drainage
at.
Cx{�erimentat Technology
Subsidence Control R'
LOG
Geothermal(Closed Loop) DTraccr 2Q.DRlf.id rttacha«1 l cant. p lc (a�Srs ae,
Geothermal(Htmtirt Cooli ReIImt) e,revnlftin under 1#21 Remafiss} tax TO 1r 0 R-
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d.Date U141(s)Completed: `_ _°�Well IDN 4/p. z3 /
Su Well Laciidnn: R,
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Physicni Address,City,and 7ip
KS
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County panel Identification No.(PIT.') rr�;�•' v��.
Sh.Latitude and longitude in dcgrcgd aimttcs!seennds or decimal degrees:
(il well field,one►among in sufficient) !J 22.Cerfirs tine:
yigt; a of e"ificd Well Cmttrnetor �°
G.Warr)the well(s)b-'r-monent or DT,e tprimry
y..t�minl;mini nin,I Her+•hv awlifj:!hat!hc"d!N KW(ware)cTm"nWLr1 a' MaKce
i,in this a repair to an existingfuel►: Yes or Nn wdrli lSA:4G'AL'02C.DI00 M'rSA NCAC.01C.'.fl200 N'rll Cnmrrncttnir Staada rLe liar!Am rt
!,/'flds;.en rc/mir.fill rnrtAntanm nvifl.tA2sirnclrAn ir►fnrmalion mid cxlrloin the nnnm:orrhe tapy nfl!r!!rrmrd fwrbpM prnvldivf In rbe welt remser.
mpo;r tinder Alt remarkc.walmt or'na 111c bark OffitO form. 2,3.Site diagram or additional feel!details:
R.For GenproheMPT or Closed-Loop Geotbermal Wells having the same cor may use the back of ibis page to provide additional well ri site derails cm"ell
tx±nsmtclirm,only C.Vd-t is needed. I'ttdiaate TOTAL NUMBER oC,vclls
construction clr tails. You may also attach addifio I pages if noeessely.
driliui: _ ___ rrtnrrnrr-r'ar rn^y�'Rtl('170NS
?.7iotat well depth below land surface: � � --(f 2ila. Bar AI) Wells: Submit this form within 30 days of completion of�vel)
PnrnrerllipfexMllrltaro!iAtprlrsldi�f�enr(esampfe-J[1Te0'and�ii 1009 cnnMetipn10the�l(Aving:
I A.Statie linter level below top of easing: (it.) Division of Water Resmirces,Information Processing Unit,
1 f xmler icne!Is Mho re rnstng•me"• 1617 Man Service Ce liter.Raleigh.NC 276"-1617
I i.llorehole diumeter: (in.) 2dh.For IaleMion Wells" in addition to sending the form to the addreas in 24,
alcove,also submit one copy of this form within 30 days of co 111011oa of well
I Z Writ construction metbod: construction to the followinZ i
(f C.Anse',mrtry,caDk,oireet push,Cie.)
Dlviston of W seer Reea»rcts.Underground iltitxtion C.ontrnl Prt>gram,
FOR WATER Sl;PPLV WELLS ONLY: 1636 Mail Service Ccntrr,Rblclglt.lVC 27699-1636
13a.Yield(gpm) 0 1{t thtul of test: 24c. i r Water CpJ Y&iolectlon Wens: In addition ib srmdmg the form to
the addres<cs) abov- also subritu one copy of NO form within 30 days of
13h.Disinfection type: —__ Atuouot: completion of fuelI construction to i the count)health depailment of the county
whore contracted.
tonnCt4-t Norrhe—linnoepnnmontortun.irr:nmrntAlQunity-Division ofwat"rWonrcr-s F Revisal222-2016