GW1-2021-04144_Well Construction - GW1_20210823

828,622-7241 p•1
1 eb 1519 46;43p Clearwater Well Drilling
WEY,L CONSTRUCTION RECORD(C:'V1►ll.. Ftlr Intemnl Use niy:
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Writ Cbunclot Name rR R-
NC well Cnninaorea-Mention Wt,mber l- R C 1NG Aral UL
TO A
G�q,nnny Name 6, R 1;It813YC f� tlpaott
TO
2.Well Com,tmellon perati tt: N• & im
i hr,tr!!MpIdt-No wall mnxrrgmlonlwrs+tts as CIJd CotmoY Stales YaNmwa.ctr)
I NVd,'less(egos&well live):
WAtersappilyglrq: m
a
Agricultural DMonieipollPubile () t►• tt. w•i
Gaothcrntal(I3eating(C9011ng Supply) OB 9ideaniel Water Supply(singic) 0• tt. to
tndustriatlComtncrciaiRcsiatgttialWatcrSupply(shttrt:d)
h A L M l4
Nan
r% ration n. (-�'1 Weer 3tq►plyVlnll:
ATonitorin Recovary
Injection p, R•
Aquifer Reebstl}e E3Qroundwtucr Itemcdiatittn A A
Aquifer Storage od Rccovery Elstolity BmTier M
L r:rttOa
AquiferTest Otnrmwatcr Drainage
Laperimenrai Teetutnitlgy [jSuitsidcnen Gontrnt
=1000thermnl
sed loop) OT(ncer
utin Olin Retuml Other lain under#21 Remarks)
-i.iVA-W-l1(s)Completed. •���_Tz)'WCII IDtJ�,_ � �• t� ` �. ___
Su.Well
(LoceNnn.'�J`i�M�
1%acility(3�rnM amc . Facility rod(ifanplicah1r)
fr
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Physir.,d Addresx,City,and Zip
AR
C 6114 Pnreel rdemiflcatian No.(Pits) r� U
5b.1.50110de curl lonjot4de in degtl'ee6/aanutafsecondsorr edmat degrem
ONvolt rretd,nncc IRMonl(in s` 1 uf11eftnt) J ? C fictttion: /
v��v� (O' 049 'f 1 �_�'
6.is(arc)the welt(El)3V8PIa7anat M Or em opt}'P r bituratere a ifntit dl Conttaotor fame
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N,Ac farm.I hr.+rl!r rmr/fy+rhm thr tnd/r4 ems(N'tu','1 coRa/nrOad m oemrAo/rao
I in this A repair to an existing ivM. Dyes or No u•�xl,1SA.gr'g+ 021:.0/00 or 13A,XAC.O .0700 Wd I Candmrsion Sdanrlar,*owl thm e
ljtlrtsisorcpnf�,/1J1otuAmnwnivetJ unxrrnuJpnirpP�rmalinnJme,rr),Jo»r0, nnnnr�Jrh� dMrlrnfilrlttrrarrlhAcbrEApMNI dMrla wrr/nwtAer.
m7air rmder C21 rasa*da:tlmt Oran IJn:Kara nfjhJ.<fnmi.
2:3.Site dr5agtraln or additloanl wall delitL9:
13.FbrGeoprohdllPT or Cimed-i.nt%p Geotbwml Wells having tha same You may use Ilia back of 1111s Pe$e io provide addidool wdl Sb dtrtella or well
c m!inirrion.anly 1 C,W i is rtoeded. rndinatn TOTAL MMAER or+.rlis c1)r&gMetion tlrhtiis. YOU tnay also OMb addigOnRI PW$If t1t7668raty.
drilledt___...� frM{'aAi.itKI'$t�C7TM
9.7ratat welldeQtA ileitlW IRnd snlf)tccs v OsfR�i 2,ts: for A1[ W�elis: SuMnit this form within 30 days of comp)tWon of wdt
J%nrmal/lprewrllc/itralldapfA�:fA�erprtt(rrnmpk-3(n?7!!0'andi(hllt►r}1 ennvtit[e(iemintbefollolvdlg
111.9tetic wat"level bdt w top of rasing: __,._.____00 Division o(Water Rtswraee,laftmadon Preeming tJltilr
(IxmlN,r kwf kr awn.cining,we" 14;17 fV afi Serviee Cep tar,jkldO.XC77MMfi17
Il.RotrJrwtrdituneter:_.S�__�" ��n.) ;2111L 1t... eo�cNon Wdle: 1n addition to bending the form 10 the addFM ill?Aa
17-Well amstroelton raetllod: � L(�t`�! j!jIa matiioon o the fo loCw'ta�of dlfe'farm wlibit►30 days of comPletJtm of Wall
0 e,mew,MM. .mole,orm push,etc,)
Division orWater Rtnatrrm%Uridcrgmmnd T1{finetWn COD"Program,
1,109 WATER 1WM.V YVELIAS ONLY: 1636 Mail Service Cantu,Ratelo.NC2709 06
13n•Yield(goal) M+eUtod of tell: - 240- lior Wstcr Sanelt &ioioeflon DVdIli: In addillen to mmding the fmtit to
tllc oddm%(cs) above,also submit'env copy of this form w11Mn 30 drays of
13b.I11sinreenan type:-- -� Atnmmr vDmpldfon of wdl ceaauurxion to the emntty howth of the county
- whore constructed.
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