GW1-2021-03716_Well Construction - GW1_20210823

828-622-7241 P•1
Feb 1519 05:43p Clearwater Well Drilling
Wn,L COS MJ&TT0n RECOR1l[GW-l) Fnr Inlamni Use Onty;
1.Wc1lC.nntraeMrinformatfon: �. ---
o J t` � t WANE ZONES ;
7RtO�f TO ASSC(tIlT10N
Well Canrtaclat Name
vC Well Cantraciat Cettificatim Ntnnber iAL OUTER CASING taolA Wed gy ORL(�ER a t
ryL a t TO nlAlifC16R fLICXN8b9 MA1�R/1�AL
a d V��rC.6 i 1 nlRt)Ut ft f� (a'/Y,
Comnnny Namr. 10 " LP-Dy ! -16.tHNER C iEYC.OR 9r11R1NG ttroraal
k� i ( � nRQM TO DtAMLT)7t 1711 "AtRWAL
Well Construction Permit .5 `-+' a� (� �•
ij.o ali appllcahfe+ue!!rnnetnrealmt parm0a(l w lJl Seale,Uarlancr•,el.) fR
n•. R in.
3.1Yci1 tine(check well 115ti): 17. E N rlttc teas z6feut
Water Snpply Lvell: ]Tacna To n AMSTkin s
Asricultarat QMunicipaNPuhlic p ft.
MR n- 'u
Geahamal(Eacating/Conling Supply) twidential Water (single) �, te. in
IndustrieilCammercinl tResidcntial WsterSupply(shared) •18 CItQVf
MA t. lfitl'LAC VT?tff D&AAfI>UHt'1'
feel^orlon BRO.tl r,, 4 h. /'/►/i/l�'�" �/-(�
Nnn%Vnter Supply Well:
A4onftaring Recovery it^
injection Well: ft. 0
Aquiferltechatgc E3CroundwoterRcmediatinn 19 SANil/G12�V$LPACK M1 a bk
Aquifer Storago and Recover} US:dinity Barrie; meoM L tattttwckrtslvt tasTltan
f
Aquifer Tcst OStnrmwater Drainago
Experimental Teeitnolop []Subsidence Contrni It. R'
Geothermal(Closed Loop) Tracer Rtl.DRII.LINC LOG adlach 1 mbar. am rouheekt r ate,
"WVTO
Geothermal Hcatin Coolinit Return) Other(explain under#21 Remarks)_ fr. fi,
3.MtevVefi(s)Ctmtpleted:�w���� Well iDN fr. 7
SO.Weil Location.
70
Pacllil�s'Iktmet ldaao far,�n� `rf bR> t g
('itysirnI Address,City and Zip r� SJ�+• `1
� v-•(- '®r "C
Camay Pareel identification No.(PiA:)
Sh.Latitude and longitude in dcgreesiminatcs(secondsordecimal degrees: -
(itti welt field,nnc Int4ong is safiicienP �r� O 22 Cerfl Lion: _
t Signature otGentSat wal Cmttrnetor Dugc
6.1s(are)the wdl(s) Permanent or DTeolporary
(SO—Perm
u..timing asix.;um,1 hr.+rhy tx1rifj+that fir wd](4 mrr{irereJ erx+er"r^r1 In�rdwrce
7.is this a repair to an existing well: Elves or 0No nigh iSA 47'A6 02 .0100 or*15A rYC-4C'02C.•d1200 Weft Cr mrrncnmr Mondardt aarf ohm a
I,r'rbis ixn repair.fin mra7m m rwdl em.wm son it xrmaliwl ma7?xptrnn the annrn•grlhc tnplt nfJlrft n'mrd hex hv�xt ptrnldert fi the well m+mcr.
r:r2nir Fodor 021 rcmnlla Arzth)ti rlr na 1/�c hard n17htr form. 2,3-Site t ftgram or adtlitional well dedaiis:
R.Fnr Genprabe/tfl'T or Closed-Loop Geothermal Wells having the came 1'ou mew use the Wick of this page to provide additional well site derails or Weil
txnsiniction,only-I G%F-1 is needed. fndicate TOTAL NUMBER of wr.11c ConStrvCtion details. you may also ttltach additional pages if nneessery.
drilled:____ __ atmurrl AT ilk �C7TONS
?,Tataf well depth below land surface: _(R•) M.Eff A[_Welis: Submit this form withn 30 days of completion of well
Few m+rhiple welLe litr ali d rprA,fd ff,,.r(sampla-4(r_+200'fnad�+r 1 n01 Clinsti=ion to ihC foll01wbw
10.Stptic wager level below top of casing: O (ft.) Dividoo ofW+'ater Resources,information Prote9ft Unit,
I(xalrrlc,tr.1lsahavd(.,asing,var"•" )f 1617111ai1 Service Center,Ftelelgh.MC276"-1617
t i_Rorehole diameter. C° (1n.} 24h.For•Iniectigg Wells: In addition to sending the form 10 the Address in 24a
aitowe,aLsn submit one copy of this"form within 30 days of completion of well
12,Well construction method: L_l L �� construction to the following:
(i o,ougc,Wary.-me,Qiret:•t posh,'40 � C
Division of Witter Resources.Ufiderground injection C011tr01 Program,
F)R WATER St:PP1 V WELLS ONLY: 1636 Mail Service Center,Rateigh,NC 27#JW1636
13a.Yield(g►m) iiiethtul of test•. 2iiG lrnr Water 411nWV&iafoetlan We1is: In addition in sanding the Form to
® the oddress(es) above, also submit;onc ropy of this form within 30 days of
13h.Arsinfection type: Amotmt completion of well constnxtion to the county health depanmcnt of the minty
Where Constructed.
I
Pam) ' '.l iJolihCarnlirtnDcpnnmentoffinvlmnmr�rniptr+city-Divtswnot'Wa[ctl2asaurcae I Rrviaecl2-222R1t
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