GW1-2022-00928_Well Construction - GW1_20220107

Feb 15 19 05:43p ClearwaterWell Drilling 828-622-7241 P'1
WELL UNS'I'RUCTIOIy ItECO]�D{GW-1) Fnr ln(crnal Use Only:
1,Well ContraetorInformation:
14.WATER ZONES
well Conmix Maine _?ROK TO DESCRIPTION
- ft. fL
V/nC'Well Cnntragm Certification Ntnn1 \r ^S.OUTER CASING for
y matlitased wells ORE LEVER ifa Tieeblt
)g'(1 , 1h I `` 88DM TO DU T (R`�,, tlf]CTiEBS MATEKUL
Camprmy Name
16. ER CASING OR TUBING thormal timed too
2.►hell Construction Permit#: iatoat I To I DIAMETER I THICKNESS IMATERIAL
0.0 a1i applitvlb/r wall Canurtrclderi permits(l.e.IRG.(7nnrdy,Smlr,tariartev.elf..) Et• it.
3.1tVeit Ilse(check[yell list):
EASe,iculttiral
r Supply Well: 17.SCRSEN
FROM ro DlAMBTtat SLOTSM THICKNESS MATERIAN imicipai/pubiic On. A-thermal(ticathig/Coolfng Supply) Residential Water Supply(single) (L fL in.
fndustriallCommercial Residential Water Supply(shared) IS.GROUT
Irri2olion ttROM TO MATERIAL EMPLAC91VIVII'M OD&AMOUNT
;Yon WnterSupplvWell: �-
�4onitoring Recovery a, ft.
injection Well:
ft. R•
Aquifer Recharge QGronndwatcr Rcmcdistinn 19.SANUIGRAVEL PACK to tiable
,Aquifer Storage And Recovery Salinity Harriet FROM TO MATERIAL tPte►CrntBnTMETltf111
AquirerTeit [3StnnnwatcrDrainage D ft•
i xperimental Technology fjSubsidence Control fL fr.
Geothermal(Closed Loop) Tracer 20.WILLING LOG; attachaddi alaheets; fneoetsit
FROM TO DES )Off ootor.Inrdsw ro{Vaetk t rain size,etc)
GeoiGennal(Hcatin ootinR R.caim) 0tber explain under 021 Remarks) ft. -fr y
lvoa
4.[late Wdl(s)Completed.� ' well ilia ::cut. ©(t. �T
Sa.Well LarAtinn:
-
14tculih:'(1Mrtct)lame F ity11V(ifapplicahle) I). ft.
. ,...
SZ)P WQ>S�C
Ph v •rl Ad'dre/es,City and 7ip
Coumy__s[LLIL.HH I Parcel tdcmi6cation No.(PiN► -
th.Latitude nod longitude in degrms/minutes/seconds or decimal degrees:
0 well freld,one latilang is sufficient) p , :i2.Ce _ lion:
Qa 7 7 `' !�P/ �l SY .
A.Is(arc)the well(s) Permanent or ©Temporary tiign lav arce"Iri well Contractor Date
,,��\\ Jiu.rJ�ming rhrs.;%arm,J hewhv cril),&that the rwwJl(.)nay(warv)crmstmoeir kt aanrdarce
7.IN this A repair to An existing well: E3Yc5 or No with LS 1.V<',tC 02( .plflll ar 1SA VC.AC l/7C.'.1I1d0 Arrft Consrrnninn Sramhnla marl rhae cr
/,i'thn is a rcpair..fill mrtknnnn MelL0rtas/raretimi ir{farmalioaarn rpinin the amure gfihc tap),rrfl/tic rreord Gas hecn frroiq"ta the well nurser.
r:•auirundrr A21 remarkvacstiml ornnIlrcHarkafthla.farni.
23.Site diagram or additional well details:
R.For Geoprohe/ilPT or CJnsed-Loop Geothermal Wells having the Monte Vou may use the back of this page to provide additional well site details or well
w.n.Stnretian,only I GW 1 is needed. 14dicatc TOTAL NUMBER orxcclls eonstmedion 11dails. You may also attach additional pages if necessary.
driltul:_._— - F` ,, _ �n�paA1.iNHRucnoNS
9,T-3t2l well depth below land surface: � U 5 Aft.) mx for Ali ells. Submit this form within 30 days of completion of well
!%r r nruhiple M•eas lio"I"d,•prhs ifdijjerew(rrnmple-3(n?100•anal i rt lace') consiriwAion to the following:
If.Static water level below top of casing: (R.) Division of VWater Resources,Information Processing Unit,
!fxal,rl�ir..Js,rlvmacasfng,fell '1 1617 Mall Service Center,Raleigh,NC274;"-1617
iL%reholediameter: �►�.�(in.)� 24h.Fur-Infection Wells: In addition to sending the form to die address in 241
12 Well eDnstrnetlon mCthod• 1 O�wr`mil above,also submit one copy of this form within 30 days of completion of well
(i
canstnwtion to the following:C.anger,raruy.ad+k,direetPrrsh,�9C.)
Division of Water Resources,Underground injection Contra)Program,
FOR WATER SUPPL Y WWFF.L S ONLY: 1636 Mail Service Center,Raleigh,NC 276WI636
13a.Yield(gptn) 'J Method of test: 2•tc.R)r Wgtcr Stinyiv&foieeflon Wells: in addition to st.'nding the form to
the nildress(es) above; also submit One copy of this form within 30 days of
13b.Disinfection type: Amount: completion of+veil construction to the county health department of the county
where constructed. i
FannGwr I North Cnmlinntkpmimentoflin+ircinmcntalQaamy-nivismnofwaterResaurces Revisal2-22-2Q16