GW1-2021-03906_Well Construction - GW1_20210823

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f eb 15 19 05;43p Clearwater Well Drilling
WE C4NSTRTJt�ION�tG'ORA{G'UV-1) For lntemni Uqc nlY=
I.weliC.nntraetor Information:
Baca,
►Vr1i C'onwelo Name
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S, RC RING ORi.I'l>Gt a AtA'reRtl►L�C aWrll Cnn11MOD1 :ertlR/ention WOW ` m of 'lilt
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CA:nn+,ny Martin �iti.tNNsR C NC AR TRutIG 1 pAtlrptA6
2.Well Com itruelion Permit#:
i.lavall appricahk rwll Cnatrnrc11e11 parntits•AV.tIK:.C.o,nNy,Shtm RIP-cr,ct-) la,
3.1Yr]i iiAc(check well use); t7 mEWEm t:se IAL
WA ter Supply Well:
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Agricule,ral wticlpaUPuhlic
Gcothcmnal(Iicatin Coati S ty R�Idential WAtorSu iv ski Ic t1- in.
� �,ttpp ) � PP ( S I
IndusainilCmmmeraiAl 0 Residential WAtetSUPPly(shared) C ,n
q MA atA
Nar Water34"IyVlell- p. �
A4onitoring Recovery
lnjcctlnn Wdl: f4 R•
gq,tifcrRechat$e E3OrovndwaterRemedistinn It1. aM11GilAVBL A L, ew tauts,roa
Salinity Barrier "laaDat m
7111
[.Aquifer StorAgc And Recovery D•
er Tcst �mttttwater Dralnngc
rimental Teclmolt,gy135ubsidence Controlhermat(Closed Lop) 13'1'(nccrTaattox hcnnal fHcgtin�Coolir,>x Raurn1 l Qtber(exptain under#21 R_cmarks)
4,11AtcWtll(s)Completed: ��'!Well I1w
_.riu.Well Lawton: 7
I:tcdity'flwr,etl&an FAcrlily full(ifappOWNe)
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Physical Address,City,and 7.ip 7 2
21. ARKS
_ ���:�• �� .ice
Cmnty - PAM61 ldetni$eation No.(PiN)
5b.t,nHtnde aml lonjotude in degreWMImltestgecnnds Or dccimftl drgretc;
(ii wc11 field,nnc intOnng is nuft'icicn!) U `32
"z-d,lrtificAtinn'
N'°
4.Js(are)the well(a) Permanent or �1f rtltt►nrpry FrpnatttfiedWell emr o"te
" !?n atl�llinR fists, ,rm,1 hRrdr�nJfj:that the,twlf(aj rror hrareJ rnntytu+7�ri �a�rr/°"cr
7.is this it repair to an oftflag well: O1tes or nNo udfll 1 SA VCrlf..•02C.0100 or 15A NCAC.02C.0I110 Weu Ci mtrnc+kar 59vmkry1,and ohm a
Ifdotr isar-mir.fill awhmnm mdi wasirr,cutin i tarmattanmvirrplain Il,r..mr I,u'r�r+ho ropy nftble tccnrd harhreti P►atHd4kf In r!u waif ml7tcr.
nq-ir raider t21 rcmn*'="n or on t1w bark nj►btx jam. 213.Stle 4"»or addit(paal wdl deW"s..
R.For G+nprnhelfipT or Cinged-1,onp Geothermal Wc1Ts having the same )r�l may use the back of this page to provide additonal well Siia dMill tn•well Ixnstmletinn,anh i CrVd-1(s needed. ftidicmfto TOTAL NUMBER of�.rlis CojLgbt,ctioO&SROs, You may also attach additional pages if nectssef?t.
drilled:_. -1
IV&S i
9-TOW well depth below land surbec: __(4) 24*- it All W h' Submit titiq fdfm"'thin 30 days of completion of well
NOniIIIiprrwettrlitrnfiAopltte jd�crent(tiamptc-3@10R'/dinif2@+i 1001 doff MipnitlthelalllO1CW:
All-Statie w�atnr level below top of easing. I G�0 (ft.} Dtvisloa or Water Reaturces,lmihrmation Yroeewing Unit,
tfmalcr low"h'nM%•raring.+rae"•"1 a 1617 Man SerykeCen ter,ibldgh.NCA7b"-1617
I1_Itorehoiedlammter: (< l a (in.) 24K In addition to sending fhe form to the addrdis in 240
,drove,abo submh one copy of this form within 30 days of completion of well
lZ Well coustn►etinn method: r �' r t'` cnnsttuctinn to the failaanng:
(i c.nuge•,mtngy.a�hlc,direct push,etc.)
Division ofWfiter Rtfimm %Underground Injection CaRIral Program, l
l'(Nt WATER 31;PI7 V WFLLB ONLY: 1636 Mail Service('miter•,Rate*,NC 270096-1636
13a.VicIQ(Rpfa) z tlRettuul nf,eal: iw; T.;ic Hor Writer Suanit&ielectlan'Wtlis In additi(u,to sondinS the tbtm to
111e pddm.4#s) abnvt;also submit unc copy of ibis form within 30 days of I
13h.Disinfection type: Amount: Wtnpletinn of,veil OMSifCC110a to ttlt Cpllmiy tMillih Bela M111t of 111C,,minty
where ennsttncred.
Fan"G%'-I Nardi l�omlinafh7inrtmenr of tiu q,namrntni<;i=d1 y-Division oY w4w Raemucac Revises)2 22-2a1 R
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