GW1-2021-03607_Well Construction - GW1_20210823

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Feb 1519 05:43p Clearwater Well Drilling
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GW- Fnr lnterrloi Use Only:
1.Weil C traetar information. t—y1,�yONE6
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Well colanclorName
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2.Well Construction Permit S: ft'
i.irtall opp/icahle well»nernrerinn parnt2r(l.a 1)K Conrxy,Sra1e Ymdame,et�)
3.ItyAl Ilse(cheek well use): "17 SCREIIN s st» TM�+a`� tKwT�u4
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�YRter Supply Well:
Agricultural MtalicipDUPuhlic Q
Gcothctmal(licating(Cooting Supply) esidendill Watot5upply(single) R
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IndustriallCOmmercial
ResidentialWAIaSupply(sharcd) B.CRQIPI To MRt�1tuL CM C .rrx ooae.tlrlotnar
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lrri^otion ft, R' C
Yon A1'aler ittpplywrJl: {t, f4
Manitoring Recovery R.
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Injection Well:
Aquifer 12echarge
�(ironndwstcrRcmcdialitm 414.SaN��ygypACK In u� �ggTptcntoD
.Aquifer Sloragc find Recnvcry
Srtlinity i3ntrier � ILAquifer Test �SulrmwaterDrainage A. �.
L>< crimental Technology [3Subsidenec COntrni
11 2(6 pRlt.ilb1G LOG ttMseh � rrop/teeite stme,ete,
Geothermal(ClosedLoop) t--t"tacef To
Csothcrmal(Hearin CooiinA Remnl) Other(ex lain under 021 Rcmwirs) ft.
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4.Date U1.61(s)Completed, _ &_ WeilII)y
5a.Weil Location, /sy�rt. �it.
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ft IL
PlIpira
I/Mgfdr�esv�,/pCity,end 7iP 21. ARKS
Cannly 1'al�l idanti$ration No.(PIT.')
Sh.t,atitude and longitude in dcgreeslmintueslsecnnds or decimnl degrees: ertiftcal I
(iF well Geld,one Iattlangit.suiru:rcnt) t J [
.035� siprlaliueare�+iGaaWeueemtrnetar Dato
tin nra unit eAw to aemrdaace
B.Is(are)the wcll(s) Permauent or � P rY al}mmS ihlA',Arrnr,I lurrahvCarrljr teal the.M11N trrtr 1Slcrtl
^— t�Ycs or (�No w�tA 1 SA tiC.K•'n2C..aIDD or JSA,YCAC.0?C'.(1200 We Cnnsrrncnna SYm'darrtr mrd rhm a
i.1s this a repair to an exisdag well: C.l J- copy nflbts rrmrel hoc bosh pmoded m the well nwnu.
1"'thin is rgmir fill Via blitItm uv41 uoacrraclinn irlrarmminn mid nrptain the amdre orncL �n or additional well detalis:
rrxir ender G 1l mmarkt scalrnl Arun dir.hark of lbir jornr• 23.Site ding R to vide additimnnl well site detail¢or well
l'ou may use.Ills lntek of lltLs pop �° a if noerssa►y
R.for GeoprnheillPT or aosed-i.nnp C,eathermal Wells having the same construction derails. You may also attach additional Page
nslniclinn,only 1 Cs1hr-1 is needed. ftldicate TOTAL/NUMBER of+yells crtniutrrTer to tl('f[OIYS
om
9,Tntai well depth below band surface: Mli 244.ForAft-UL' Submit this form tiviihin 30 dale of cpletion of well
1%rrnnrl�rplexellelittnl;d!prhrjdif/'errnrCriamph-3n.Id�'aadZ�i+1l(109 eongirouiontotbefollowing:
(1l) Divitioa of Water Res6arccs,Information Processi�B IJtdt,
I0.Static water level below top of CAM09: . 1617 Mull Service i Center,Raleigh.NC276t"-1617
!f sealer lercl is abntle caring,Inc";- (J
l I-Romhole diameter- l/�� OV CA.) 2th.—Ii al Intection_one of t hisaddition �hin 30 dam of�pl�on of well
above,also submit one copy
IR IVe1t construction method: Program,
rin
to the fotlawin�
0 c•nuns,rotor)•.wble,dircct push,exc.) Division of Water Reeace urs;Underground injection Contra)Program.
106 Mail Servicit Center,RRICIO,NC 27699-1636
ROR WATER SUPPI-V WF.I.L.R ONLY: �¢ __e......s�•&infoMlon 1�'ells: In addition to sund'alg the form to
Method of test: 24c, also submit one copy of this form within 30 days of
13s.Yield(gPm).. �i® the addross(es) above,
,Amount-. completion of.veil construction to the county health department of the county
t3h.Disinfection type: Wharf e01191turded.
I+nun CtV-1 North Camlimt Dcpnrtmont of linvird'"ne cull quality-Division ce Watrt pcsantx�ee
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