GW1-2021-03682_Well Construction - GW1_20210823

82M22-7241 P.l
f eb 1519 05;43p Clearwater Walt Drilling
WEaC OONSTRUCTION)1iEco {G'W 11., or inlelmai UBt: cry:
1.W�C�rntraetnr 1nR/rtnatton: ""—�
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%Veil Canaaact NameUlm
+ic wit Cnntraelar CaRification AhtmtKr dtl7'ER �
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CamtxmnyNamc a5► ji,tJVIYER NG 1
TA nUb1LT8yt '�
1..1Veii Construction Permit &
i'lrrdi aptdicawd wma maraorionpmmltr(Le,VIC,Cnttttry,.201A Yartou+ca.cry)
tr. R i°'
3.lYd)flit:(Cheep lvdl lot)_ 17. To in.
tC ®a ua
water Sappfy�Ven;
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Agricultural DMonidpollftbiie () a d"
Geochcrntal(lientiug/Conling supply) F2Ae5ld=tJaj Water Supply(single.) IL
butustriaRCommerow "}Residendat Water Supply(shams) Oif1 da
T
irrl Dl1On 1 fl.
Noo-VI attr Supply*VI ell: ft.
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R4onitottin Recovery _
injection well., tt. it.
Aquifer Ree lstr D(houndwaterRerncdiatinn a9 1fAL A a c MtE77ron
Smit011t L
aquifer staraye sold RDCovery 13Satinity Barrier IL �
AgUlfCr Tc)t
Suhaidence Control :R R'
Lxperimenmi TeeltnDtngy LOG
GOOthermal(Closed Loop) �Traetx
71
Centhcnnal HoE lin Remm) a*cr ex Ain under 7l Remwks) te. rt
4.Date:Wdi(s)Completed, 4-1 -Z► well11Nt
Sa.Well Location: --
� IL
l teility:m(ltraMNmne . FAdlitylD(1(if9tPOCRMr.)
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Physirnl Addresx,bity,fluff Vp i rev
t.,nnty patcol ydom(IIcatitm No.(PIN)
5h.l,gntude attd hmgltude in deplreea/otinutesJsecaads or dccimnt dcgrcar. ---�----'
tenon:
(ii pelt trod,citeDM
lnt+loan in ttdlialattt) o � ��.CertHiea �'�� _�I
Sint of(krtif+odWdlCnatmatar
6.1a(arc)the wdt(ajPtartnancm or©ITerltpAt'RfY Ja aranrdxtrr
�v /m1mJ rhJx.(nrm,J hrt+e7ry rsrtlfj+rhet tbr.mtwU(j corns(hare)rxiMfJtArAIYJ
T.in this rt repair to an cttitdttg wdi: nXcs or ZNo w> DX:.O/00 nr iSA�Y(:AC'11X.'.flXIU W'rf!Gontfrnction 9randnr6r m�!rhm a
beff'rr,Jsem sepals.f111 mrrbmowe mudlt.ra+utn+urnn irl/i+rnwilneanr rrpleimr the mrnntre!?f Bu
pgfJlrtsnxrmthopr renProt-ad/nrJxtwellAwar.
rr,,virander rZt rema*rcufmf orrm itu:Ai rkafthlsfalm, q;.yft dytgtrtun or Add[tlor1tl1 Wall galls:
8.F'ar GeoprobeA FIT or(3�d-Loap Geothermal Wells having the same loon to A use the intCtc Of MAY
Rita to eb"lido ons'limlai ti fli t)ite my'dia rm well
uonstrnctien.only t GWl iSneeded. fiWM to'POfALNUMMnfwclis
cUngtrVatit)tl ridails. YOU fogy also attach addltiotret paces if ntxxlrsery
'►.7foWl Wetl tkpih 1)eittH'loud�utiNc A47b fore i Submit d1t4 fomt tivitlnn 30 dnys of comPletten ar wetl
i,arimulaptc wens vtrot,dopqujdBfarenr(cramp/e-3(IOA"airtr,rfDnq Cammmionto the followft:
10,StaGe wralorkV41 beMw top of easiagt (R) Dlvistoa orVYatcr Restwtxe,'W!n mlation Proccasbg U1114
Jfwater firm'tvAimrWnj.,tee", 1617 Man Rttr*oCenter?Pa1fth.XC27(►Wlfi17
IL N fle tole diameter. � t'�(in•) ?itb,1 t�t^r 14 Walla. ht addition to tiant[itrg the forte W�addtasB in 240
y� above,sitm fmttbmit one copy of this%oft wilbin 30 days 4f nomFtatktn of wdl
12.W eli mnstrnelhln lnetbedt ��^--'' 1 Cnnstme ion to the fallowing:
(ic.mige•,-toy.cow,pir"ptlthm'a')
1?tvislon afVEtUer Rtamlites.lJndergrnnod#gjectMa Caatrol Program.
gram,
WATER 5tPP1.l WEi I,S()lVLV: 1 rM Mail Service Center,RAtelglm.NC 2709-1636
13A.YittA(upat) ly[a!titotl of tit: 2t c, leer�lofer—'4fl�y&jRjWj on 3 d& ft)addtidon to Bonding the Ibtm to
^- " ' — the ndth4ss(t s) a6ove, sho subtrnL one copy of this form within 30 days of
03A.olsinketion Amotmt: completion of wail construction in the Cmutt) health depadtnent of the county
type: ---�.- share eaflBtracttd•
i owl GWU i North C amftDepanmeaut or t:nvjninmtxutnl Qtmnty-Divmsmasf Water R"Umamma
RrvGmed232-201d

i
Well Driller Self-Grout Certification
C+wner• �� �'G�A W QUC��Vew WeIl:
Address: 9,6 Repair:
Permit: C�NC1e'
�� - ate►
I hereby certify that the above referenced well was grouted m appearance in accordance with
all County Well rules.
Well Driller: •,TCr b PU.(Yl'(Y`sC ._ ? Signed:
Certificate#: �A \ "� - Date Gro q
Construction: Grout:
Total Depth: �9 �� Type:
Casing Type: yC — Thiclmess: C12i
Casing Depth
Depth:
Diameter: (_2 ,
Weight/Thick:
Height:
Drive Shoe:
GPM: 3