GW1-2021-03748_Well Construction - GW1_20210823

1
Felt 1519 05.43p Clearwater Well DrI in9
W18LL!9QNSTRUt ION MCORA(GWI Fnr lnlefnni Use lily-
I.wellC,nntraetar lnformatton:
iYrli C'nntraaa Namr
s, R C G br in at ae rut
a nsl►reaw
VC Well Ctintoctnt Certification Ntttoitcr
TO
/a
C.On PonyName ? ^g 2-4 ^•16.liYi'tSR C lYG � oal 01At 1tA -
rm ----
La ►fJ l� , M T
2.Well Cnnsnnttinn Peff isK: 2 `( e L ud-3
i.ixr air n/>1,licnMc Boa;l cmurnralnn/>armns(i.w i1K:C_annry,Sral�Yarfamv,crw) � .ice �—
R•-
I.Wdl tine(ehMk wd)list): 17 N n A eae ut.
WO to Supply Welt:
Agricultural DMilnicipal/Public ()
esidantial WRITS ly sin le tti t�
Geothermal(.Iaeatingleotrltng Supply) �R "pP ( )
Residential'{Water Supply(shared) OUT A w snerTac .R a
IndustriaUCnmmerainl T
lrri noon R. R.
rVtrin yaller Suppl^v VI ell: ft.
Monitoring QE
RCrovery
injection Well: tt. R•
Agnifcrhecttirc�c }GronndwatasRcmrdistinn 19 AMllGRA Lett r.
AquiferStanageandReeovery �SatinityBautier IL ft.
Aquifer Tcst [3Staranwatnr Drainage
LxtTrrilnenrai Ceelmaingy 13Sutsidence Control fe. D•
xa,pRtt. sec.
Geothermal(Closed Loop) �T�e raOEM
• Gcott_icrnial(Heatin6aotimt Rewrat) Olber fallolain under i)21 Rcrnattts) tt. (L4-7
4,Date:U"dt(s)Comple�ted,.12-3 I
Su.Well L ntstdnn:
a VA
l�:tttility.`[Iaotr�erTlgmto �� �� - t:anlitytDiT{iftgtplicghtr.) � �
4 <.
1a"�siwnl Address,City.and 7.ip
(`vmly 1+nteel idetnilSentittn Nn.(Plh� \`:�`�t O�
5b.Uttitnde Mid Innfiltude.in degteslTninntestseconds or decimal degrets: —
(ti.voll Gold,Ong int9onainsnrt9eicnt) e a ,Ltrtili oall
l 8ipitmaraof -Miiodweu�Ctttdmia�r late
6.Is(arc)the well(s)MPerrnanent or Direat"rgry
ku atyninll rhra_ ,rn,,I h0VAV-WjfY th Uir,nwJl�aJ tit fwmrj rt Wnwj °�M ce
i,lY this R rrpalr t0 an ert9stiag welt: Xrs OP + Pin ud�h)$A 4CA(•'02C.41(lA Ar lSA.VC.AC A?C.'.P2n0 R'rtl Ca rsanenna�Yaralm+lo mrrT+hat n
ffrl leis;>1,gwsr.fill nurlmnom mall aonsnvcrinn irlfnrinmlon mul crplaht thr,anitrre"Phe ''npy of elite rI hacbeM pMldded 11)JW wrJ!m11
r:.pnir render II remrrN .YMM orOnJIM back nfrilp fnm+. 13.9ftt diagram or addidonst wan detafla:
R.Por GreproheltipT or Cle"a-Lenp Geotbermnf Wells having The same You may List a►c back of this page to provide additional wed)site details or we11
IMMSITtIrtinrt,onit I CT%r-I i5 needed. rlydicuiq TOTAL!NUMBER of wrllc �an9trrte710n rltKailS. You may also athich additional pliges if lleccmiltVv
drilled:_..
I
99.Tntal welt depth below land surface: US _(R) 14A. 8or All W its: 3uhmit Otis form within 31D days of eampltdion of well
l"nr netdlrtple wed MI11lldrpllxr ifd(Q'¢rnnt feu•mnlrht^3AIM'drnd 2 1091 I:ansfirGinn to the Making:
111.Statie water level betnw top of easing. (D.) Division of Watts RagmrtIM Information Processing Unit,
1/'�m/rd/�nrJ lx MMta caslrgl.Inc "t/ 1617 Man Servlee Cuter,Raleight NC 374"4617
ti_fft►nettoieAlaraetcr: { An.) 94h.For Injectiga Welts: In addition to sending the form to the address in 248
t ��y �� ,dpove,also suhmif one copy of this'ifa m u4thin 30 days of completion of well
17-We"construction Metmid:,, + r A4:z c onStru tion to the foflowing
(i e.mega•,misty othle,drrectpttslb ctc,l a
Division of W attr Rtaalnres.Undergronnd Injection CORifal Prtlgrnal.
rOlR WATER Sl:PPI U WRLL3 ONLY: i G36 Man SeirtAce Center,Ratelgh,TiC 270961636
13a.Vicltl(Rppl) ^ i►Iatb+ut at laser_� 9.4c.,1'ar Water SunDly&iaketion With: In addition to sanding Ilse ram to
Cite addrans(es) abnve, Also submit aide cope of 11119 Win wi111in 30 dtlys of
1sb,ntsanfection type:_ - _ Amotmt^. _ rampletlon of%V41 aalnsifuodon to the comtfy health tkpailtntat of the connly
Vitme eaMUMCMd.
I'rmn I North Cnmllanskrnmm0711.of I{uvironmantnl Qrmlity-Divismn of Water rt oln ttGs Revised 2 n 2a1 R