GW1-2021-03846_Well Construction - GW1_20210823

828-622-7241 p•1
eb g Q5;43P Clearwater Well Drilling
WEx rL!P()N MM10N RECORD 4<GW-11 V or intemni Use 0111T
1. d (.`.nntraetnr Information: �. — -
�� {may
1 i 14.W EONSS �N
1'lanxt TO A119
WCll Conuaao"rName tR !t'
Lr - Ii-
VC We11 Cnntradul CcKifinotion Namber •� R t: AVG t a MAYERW
C—Al a_'�W Ic UJ C.k! Tyr i i 61at/M tt. °" J
t` (� 11u� tr: - ► n.
CompanyNamc ! N f3.{1YNIMCASINGOR tR NAt1WAL
��p r� � yR TO
x.Well Comitrnctian Permit d: �/\J ft. w ("'
Lin ail oNdimAte well ammalrote porinar(L n{Y Starr Ym'r-0-err_
3.1Veil Ific(check well use):
17.8CItB r0 egeitttttrslst n Tq►Clat68B ?BRIM.
Water Supply Nc11: a"
Agricukorat �MnnicipaUAthlic (1 D tt
Garchcrmal(IieatingfCoot'rng Supply) it Residential Water Supply(single) tt (O
I idustriattCommereiai E ftesidemial Water Supply(shared) -1� OiPf Ma L �.K 11&6W MVr
am To
trri ution rt. n.
Nnn-Water Supply Wall:
monitoring Recovery T
it• fc.
Injection cl:
Aquifer ltechnrge Q(irmmd><,nccr iLrancdialitm i4.3A1VD/GitAttBL PACK a lda
Salinity Bfltriet ROIL[ M L pHltACnME ME'1'1tdD
Aquifer Storage:mid Recovery }• - n-
Strumwater Drainage fz
AquiterTcst Q -- �
l L"xperimental 7edinnlogy [3SubsidMee Control 0'
Geothermal(Closed Loop) �T[aece Ffi.DBft.L1NGLOG eh � .rc.aa1
p60t✓r .�
Geotitermnl Kcatin Conlin Return) Other ex in undor:g21 Rcrntuks) 11t. M
ft. ft
4.haft,well(s)Coi"leted• wen low
5a.Weil Location: •��-- R. � l( '
r Facility[Di!(ifapplieWe) _
l�:tdlily:rlumerNamc 1t. �
��' ►ll C • Liman Ml�kst �C n. IL `3
Physical Address,City,and ZipARKS
f1`(•j.J
Camuy Yatml Wcnliftention No.(Ynctl
5h.Littitude and tonpltude in degreesJmtmttes/secondsardr�imnl drgrccs;
(ii well field,one laftalj is suilteicnt) 1 1?'CerliG�tion:
�- fade
�;Qaai,��rcxelr,.yr vletl ealte>laear
6.ls(sm)the well(s)dpe rmatsent or ©iTempornry f/ mar rLe arts h+oral cox ra l nt ocuorAn
1F.�f/imiot;a+rx tour».ihenrhvrad'fy -W4
7.tethisa repair tnancxiyBDgwd1: �Ycs or �lVo "`rrirlSA:�r:.'AGn2C�JIOUnr1SA,YC.itClllC.f/21101Yef1Crrofrarxra>ts<+ta�°i�•r^a'1rhOt�r
,rrl,ia is.)rgmlr••fill Our NoWn Wdl roe urvellpn i,�,rmmlon oad rtprairr 16,aan.n-..(.hu
e+,nY nj11r11.Gear.!hoe been ptovfded rn rile well ntvner.
r.;ro;r under t 11 manta.vxrldn or on 1he hark n flhfs jorn,. ):s.Site diagram or additioltal Welt demtib--
luau may use file back of this pogo to provide add'tionnl we'll idle details or well
8.for Geoprobe/DPT or Gifted-I.anp Geotbe m l welh having the snore Gyns�ion drlails. You may also attach addiCu=l pries if aoccssery.
ixmvintctian,oniy I OW(is needed. fndirAle TOTAL NUMBER(Jf'%vclls
/ �r1tt,,�'-;*-*wT j.�+�i'Rllf:iTn1VS
9.Total well depth iteiow land surfRec; (D•) 21a. FM'All Weis: 9tis fort ntfthin 30 days of completion of wet!
r ar m,doprc wrrrr utr ar;d pt7,s ifdr�arrau(example-3(n114(1'nnrt ski 1n0'1 enn3►t Mi00 to the j'ft11o1,ring-
10.$tn6e water levN below tap of caving: 00 Division of�tiater Resources,lnfntrmatIOn ProcmiBg IJfdt,
I A.st alie water
ev hding.owPet top
fill 1617114MR Sen'iae Center,Ratefgb.NC276"_Ifit7
t I.Rottehote diameter. l� e (in.1 2t16.For IwMrtien tY tic to addition to sanding the form to the nddras in?Aa
f above,also submit one copy of this form within 30 days of compladcov of weft
17.Well construction method: ( a►t auction to the following. i
tic.an gm"mtmy.cable,ditroct pitch,ac,l Division of W ater Rtstlu %Underground injection Contral Program,
16 C ^>636
36MalSe9eeir, , 74
i09 WATER Mpp!V WE IS ONLY:
13Q.Yield(ppm) Method of test. _ 24e. 1 rr L:atcr Sattolt c ipFcetlon'G►elis: In uddilion to sanding the fort to
the nddmoss(es) above, also submit one copy of this fort within 30 days of
ramptetion of%veil construction to the county health depprlment of the county
13h.Disinfection type:: -- nrtsatmr. where cortatmeted.
Pom1 GW-I Noah Ghmonn t)apnotnont or linvlrcinmrmtnl Q,mtity-D vismfn o Wort'Rasmrreas
ltevi4ed2 22 2atb

Well Driller Self-Grout Certification
Owner: 4nQe4-Jn TV tl i New Well: y"
Address: IUI Ai l 1 OffZ A6 Itq?air:
LLA4Pexmit:
SLu�I
I hereby certify that the above referenced well was grouted in appearance in accordance with
all County Well rules.
Well IhUer: J®Sh P1 ,c)n s Signed: //
Cerdficate#• 4 f 3-7 -Pf Date Grdu -
Construction: Gm.ut:
Total Depth: tP � Type:
Casing Type: Ve n iftess: /Yll
r
Casing Depth: yo Dept: ay
Diameter: f&`/
Weight/Thick
Height:
Drive Shoe:
GPM: