GW1-2021-04587_Well Construction - GW1_20210429

Feb 151905;43p ClearwaterWellDrilling 828-622-7241 p'1
WELL CQ(TORM ON gECO GW 1�. Fnr Inumni Use Only:
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14r. Pareal idemiticatipn No.(PIN) DtiN
.riti.Latitude aml ionjpitnde in degreWmimrtesfseconds or decinnal degrem
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6.Ware)the"dI(aj�i!-=nertt or DiTetaporory sionalwe afOetifiod Well chaft or Data
11v atpnlag tnM.(arm,I hrtwAv rstflfy/het the we0(4 mrs(W-4 C-0-AW&—Aence
7.h this a repair to an a dl tang well: Oyes or WNo r•%tir I sA jog A4 02 _atoo or 15A j AC.02C.0100 Well Comirndtan StWxA2r r mvi thar.r
;rt/rir i�o-pain fill mabmwn mdl.!asurucniw i*,vealtna Lnd evJ*in the w"re 4�jtbe wpy nfrkls rrmrd has 6re0r pmOad/n rJx!waff owner.
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2,L cNe dir+gram or additlaml well deWNs:
8.For GeaHtrahe/11PT or gonad-lamp Geofherrm►i Weill having the-same may use file back of this page to provide additiom it wen site d eWh or well
mimnicNaxt,only I GW-1 is needed fndieato TOTAL NUMBER of wells c+msutrcticmn details. You may also tdtach nddifionet pages if noceasary
drilled: l t, Slij)at1lI IMALIN_rjjlfC7i0196
9.9r4t11 well dteptA fieltttr land S1tHHcC 24;y, for A"_Wsiis: Submit this form within 30 days of complaion of well
/%ar raelUpteW11s UNr off d.tlrrlrr f4V,1,L r(;aatp):-3 r(h•100'and; 100) COnoudi0n to the fiiIlffft:
IG.3tetie wetter level below tap of taxing: 0t) Divis)on of Water Ramu'cce.In%rel ltlon Rrocmft Unit,
{famrtr.r1rreJJardvivecntftrg,rAr'�" k 1617AingSlarvkeCenter,Rddgh.NC27dWJ6i7
li.itomhotediameter: c tf a/ An.) 24b Fnr Iwkctiou FA�. In additiod''to aonft the form to the addre"in 24o
1 above,also submit one Copy of this fO m will t 30 days of cttmpledim of well
12 �Yeit rnrtltrnetinn metbed:
tic.sage-M. .cable,ilirm push,etc.) consttuetiotm to the fallomving
DlvbMn of Water Rem wm%Underground injection Control Program
FOR WATER fitTMY WE'LI S ONLY: 7 rim Moil Service Center,RAlelgh.NC 27ti09-1636
13s.Yield(gpiril J Menia l of tesl:� 1�For Water Supply&IoiaetlOrk VYelIL In addidon to sanding the tbvm to
the addX"(cs) above, also subpar one copy of this form within 30 days of
rib.Disinfection type: Amount: cotapkdon of v61 crnuWction to the county health department of the county
Where congract'ed.
I�mm GW-1 Nar/L Qamlfea r!eparrmant of r:nwiniummtnl omdity-Division of WaM Pom=es ReviaeA2 22-Z01 fS

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