GW1-2021-03721_Well Construction - GW1_20210823

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Fab 1519 05.43p Clearwater Well Drilling ••"•""""'
WELL!QQNSTRUCTIUN>lzFeoRn(G'w 111 I or intemnl Use nly- -
1.W-1f CAntraetor Information:
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Qeahcrmal(licatingtCooling Supply) eaidantiat Water Supply(cingia) tt. !L �'
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in eetion Well: ft. IL
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Aquifer TrA j3ftrmwabcr Drainage
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Geothermal(Closed Loop) DTtaset TO
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A.Date Wdl(a)C'.Dmplated• _ Wee(ll IDN ft, tt.
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5b.t,atitu(1e nrd ti mAitade in delp'w fndnnte-gtseconds or dccimnl degrees:
I�vett fr ,one iet+lang is sutllolrni) V �.Ce lion:
Si af(knifiodDJ 11c, actor Base
6.]s(ar e)the welt(a) 'Crmaaem or �I f emlmrnrY
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:.In this n retire in an existing weft: Xes or to r ISA.sr1:'A['021 .Of00 nr ISR NCO-02C'.f1I110Wett(,'altrtrnrrtan 10awknds mot thm a
�rImtliK-itrepailttoan wntiKeenan,utnnirvo$+ ll6lsmranikope hwptopwdlarhewort twnri:
rr7oir under e;/remarks arnan or m Or twrkaf thtsfornl site or addftlonnt ttraU tlatalta:
1'ou may use lite buck of d1h page to provide addItional wen site dolelh or well
8_f or Geopro6dlf!?7 or ptmed-i ttnp GeotitormAt Welts having the same �Ungtntetitso ltrtaiTs. You may also tfch addititmet page&If nncemm.
unnsimctitm,only I CTW1 is needed. rrWiawo TWAL NUMBER nrvrclls
drilled: _ ,,,, t�rurw.art+rAY t1y41'RUGTiONS
9,ToLit wofl*pth flelow(find sut9itcC 30 f ) �+/7L tFer A, ,_ R? Submit dtis ftum�vidtin 3o days of c{rmpldion of well
per tx,dNplc wtlrt Gsr ali dePrj"004r ant{rtRmpla-3RIVO o,rt!'r 001 cnnmuctitm to Me following:
10.Stnife crater level betnw top of easingt _ __00 Division of Water Resnurns,laibrmaden PrvcMi g Unfit,
{('hirer tcrrt tr iAvine cttrtltg the ilil7 Mail SeroWo Ceatert Mtef®I 14C276944611
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!i.Rot+etiote+finmetcr: 1� (in.) 7,eb.z^-a�a'cHon lYe0s: Tn addition to Aandmg ftfoda to die tiddrets in 24a
alcove,also Submit one copy of this form wilbin 30 trays of compltitlm of Wdt
IZ%Vcll construction metbod! ` v T - 1 can auction to me foliWArt,
(i C.-IF.rotary--bk,Qi"a initil,stc,l
1)Ivlsiott of W ater Keamtr'cca.1)ndcrgrouud fgjectlon Coatml Program.
V(M WA'i'F.R Fcjwi.Y2W(E�t.L,S or-JLY: (� �+ 1636 Malt 9ervlce Center,At leto.PVC 27094636
I3R.Yield(Mml ) Me"W of lest: l�.;_ .. 2 tc. Rnr Y,,,�a!e��+u»n1v&t,---°ieett°n—thefts In addition fa-sanding the norm to
die nddrkms(as) above, also submu one copy of this form wfdttn 3t1 days of
tab.Dicinfcetfart type: _...,� AmamC compteNon of wall construction to the'emmty health depentnettt of the eemny
where aattattaare0.
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