GW1-2021-04580_Well Construction - GW1_20210429

Feb 1519 05,43g Clearwater Well Drilling s28-622-72�44 p 1
WELL LON RLq Gw,>t �' Far Tnti mal Use Only:
t.Welt CAntrnetor Inibrtttation: Q1Wx
o(1Lt7 M0V,/) V w zoxHs -
tVet'i Cmuratxa nftmd �x�
rvlCWdlCcmtnclmCe4lReatienMmd toetieatd OR
��� 1�.1t��� '✓�1 f (l nq I 1 tr, TO tt. In. r
rtw.
�-
CnmlumyName cctt '' .^� rrnn`' (�j i6.LymnCA$iNBtmaTtm WG ttaeoat4
2.Well Construction Permit tii: CJ W I— Q V T—1 x To 0"Mc a "ATZMAL
Fdsr all aygrlloeltle well cva►rrramlon parRrlLc pa i/!C.Cnmxy,Sta/x.Yarirmcr,.:rG) B.
s.tivdl 1111!(t:kedt trill We):
Fwm -A
WatcrSapp�y WcR; t7.
TO I n1AMaym T—BlexHas 7teRGL
Agricultural onic(pnUPubiic 11 A. ft
Geothermal(IioatiaWCadlttg Supply) Oidentiel Water Supply(single) it. is
tRdus1ri8VConuoeroiat DResidendat Water Supply(shared)
err{ utitm lxC1iQ11>C
T l7AT6 L� SH i1" sieA
tYon-Water Supply Well:
Menittnieg1311ceoveTy p, fc
lnjeemm Well:
Aquifer Reel tar$C Qfhoundwater itcmediatinn
:)Aquifer 19 M1/GRAtr13LPACiC a
A !eE
qu Wage told dtecovrary Salinity earrie� [moot a ttlltrue tKcnwo
AquifcrTcst []Sto mweurDrainage n- tL
EXperimentai Tecllnology 06-ulti dencc GDntr0l R-
GeCtheonal(Closed Leap) ©Ttacer 2tF t)R1LLiNG LOG
CTO Me
enthermai ReAsn Return) titer( in under P21 R mLfl ) ate
tt. fr_
a.DaftW-0ll(s)Completed. j��. VWell IDY R' �at ft' y-aa" !(
Well Laeattnn: A.
%acilitj:'fhandrName . Faa'1ityi[hl(ifapplicaMe) n' R'
19a4 �d, i re uc
r�
ysicnl Adrlroax,City,and 2Zipp�1
y
ldt� �d nJUMARW
C 111my Pavel rdmuSdation No.(Plus)
rib.Latitode Rant itmilitade in degrmsfadmites/8econds or decimnI degrees:
6fwrll fidd,one fat%ugisaninetcnt) =Certmention:
6,13(am)the wd*oz!•mautnt or DTewporary si Iare of oftilricd Well Ctmtmoter Dist
lfv alimmg rlslt_,`.nm,I hrmhv rwVf,Ihat r/trr two!( xnr iirareJ CWWR e W in aem►de9te
i.in this it repair to an exirting well: Elves or ON. udrh IJA tiC:'AC o2f.0/p9 or IJA NC.'AC 02Y.'.0200 well Creuroct+v»VVAVkr*rmt,AM it
6"(111s ix[.rgmlr fell maktmwe wdl ewwmeilnn in rmatlon mid exp1bh#the unwer,rile r/'IrJ'ofdds rtacmd Aax,X"prOP(bd 10 theWC(I Aglt[r.
r, irnnders:Jrewtfaxcitantionlfd:bar*oflhisfame.
7'l.Site+dshtram or additlomllvell deasiD:
8.For GeoproheADPT or Cooed-Inop Geothermal Wells having the same 1'ou may use uu:back of this pegs to provide adifitiotmi well site details or well
conshuctimomy I Gw-i is needed ihdfmta TOTAL NUMBER of wells c1M4trudiDo deals. You may obw adach addifionei pages if nommiy.
drilled- _ )gMG•A,l.il,�'HAU('I M
9.TOW Well depth below land sutiltcc ' (4:) 24 for Ad ►ells: Submit t iii form within 30 days of completion of well
r%r:rnwli)AfrWeRs6wafidO49wf4Wdram{araatplc 3tFFi1Ip0'aui"nlOO7 consMiction101htrollOvdW
10.StpVc wearer level below top or taring- (ft) Division of Water Rewmeca,Inihrmadon Precessieg Urd4
(1'ware.r foral k rdvtre cmfrrg,rac••" 1617111 f Service Center,Raldgh,MC274WIS17
!i.ltonthotedtametrr: `� o�n (in.) �e I 24b,per twiccHon Wills: in addition to rending the form lo The addmo in 24n
12 Well twmtrnettofe tnetFaede cDnAntetian to the following:
1t t� � above,also submit one copy of this fot'm t IGM 30 days of completion of well
1 c.Well meaty.calk,direct poll,Ito.)
Division of W titer Rraotwm%Undctgreund Injection Como)Program,
FOR WATER SL7MY WELLS ONLY: 1636 Mail Service Center,Ri►teigit,NC 2709-1636
1X Yield(gpm) �IS. Method or test:_ Ise Fer Walcr Solely&Ialeetlan Wdit: 1e addition to sanding the lbtm to
the addresses) above, also submit one copy of this form wi0tin 30 days of
tab.Disinfection type: ,Amotmt: comptetion of well conSWcnon to the county health department of the county
Where constmeted.
Dram C.W-1 North Chmlfnn Depmfinent of tinvIrdnairmtal QtWity-Divisum at'Water R"Moves Revh"2 22 2e1 b