GW1-2022-01038_Well Construction - GW1_20220107

Fob 1519 05:43p Clealvvater Well Drilling 828-622-72.41 P'1
WELL ONSTR7-7rTInlV REGOR;I,IGW l) For intcrnn(Use Only:
t, tCrJntraeMr inform ition:
�KWATERZONES
kvcll ContmiLw NaJne — wtow Tn AESCRt't lON
tr. fr.
W:Welt enntmNnr Certification Numbe (1 g tX)TFR CA,51NR for Iroltb creed%vaLr OR i.LVER if a e
n � `1� _.,p p� 1 (� �l n NRiM i'p PI t M1tAtCR
l.nmpnny Namr.
11 rr�� Q J 6.INNER CASING OR T1MING rhprma!cin Wo
2.Wril Construction Permit ft: L V 1 M IROM TA CIA rt Tar, tt MA L
i.lr7 rill n�rfirahlr uc)rcrntuntcUAn/uumur(l.rr.U/C.C.nunry,Slalr,lfArmnro,ac.) fh k in.
3.1Ycll Ilse(check Well use): n' h. ia'
WatcrSapptyWcli; 'ti.SCRBEN
To I D A S r ESA 1MATMA
rAquifer
ultural Mlmicipal�tlblic (l t<. tr, in.
hcrnlat Oftatirig/Conting Supply) �¢Rmidentint Water Supply(cingte) tt. tt tn•
triaUCommercial Residential Water Supply(snared) Is.f. OUT
IIOn PR` 7. 1MATERtA1. &MPLAC .C!tT PTN D ailml,
ater Supplywr.11- W� ` ft" a R. ffl
lorin Recovery to fr.
n Well:
rcr Rt:chatgc Qf;roundwntcr Remcdiation _..
er Storage and Recovery �•'�Cniini [Jnirier 19•SAtvO/CRAVEL PAC its hie
Y..i ty PRPM TO A IA LACEMEtiTMET)IOD
erTc;t 13StnnnwatcrDrainage fl-imental Teehnology C)Suhsidencc Control tt ermal(Closed Loop) DIrace, 20.DRILLiNf:LOG I rB fcnnal(Ncatin ootinR Rearm) [()ther(e,tplain onderfl2I Rcmn!j PROMit. SOD a
m e tutor, rJrocktlPc,RraMtirr,rra)
a.Date Welgs)completed. Well IDhf rt, t ` l
Su.Well I Deation. rf -7 VR 1
1•.tnlrt�:'tk,,,cr?learn Faer�rf:q,pllcah�f
Physical Addre,,,//riity,and zip
21.A>SEMARKS
Coum^ y` farce%&Icmirentiem No.(P(Nl
�tr.i.nHlrrde and Mnfiitude in degroes!minutes/secortdsordccimAl degrees: —
O.'%wltfreld onetat4onaissulticlent} ;12 ('! Reatlnn:
6.Jt(arr.)the well(s)i >Bpermnttent or ©)Temporary iu nlure afC.ertirrral WellCtmtrnctor Data
"� It.%Jyning W.v firm,1 herrhV cwmfjr that 1Ar u¢!f(s)am(were)r.n1AwIVf/irl h,occnrAa7cr
7.1:,this A rrpalr to an existing well: EIV" or 9*o «J1N LSA.ti'r;'Af.'a?.C.II/ryn nr J.rA,Y(:AC n?C',I1a10 fYr!tl(:'r nrlrtrrriuu NnndarA.r nrerr tune r.
('fh h i,y;r rc ir.f!/rmrk man writ roasir earn,it%foamlian Mir/r.rp/nin 11".Dann,•n(Ihc rrrJr nr//rfc rernrd hoc heMl7 prDlti�Afn r)x wiril ntv77rr.
r.;anir rnrd:r t?f rcmnrin scrirrur ar qrr dn�har'A n('lhlSfomr.
2.3-Site diagram or Additional Kell deEAils:
R.For GeoprobeMPT or Cltwed-i.,00p Geothermal Wellrt having the same Vim may usr.Iltc back of this page to provide addiGonnl well site details or well
rxnvmretlnnt Doty I GW 1 is nreded, Indicate TOTAL NUMBER of wOls construction deans. You may Also attach additional pages if neCES9afy,
drilied:
___:....
9.To tat well depth betels lands rent(e: __(RJ 24h. JrOr J�Mills: Submit Nis fbrm within 30 days of completion of%veil
Prrnrnhip/[>.ellcliSrrtfidPtltrifr!�crenr(ranpl4!(n�1p(I'arM.@,mn•1 "
construction to the follDiving:
10.Ctntic water lrwei hetow+top of easing:,__ (ft) Division n(Water Resources,Information Processing Unit,
11«nice fntu!b rrlvrva eosins,rrer'',^i — — 1617 M1an Service Center;Raleigh,NC 27694-1617
ltnrchote diameter: I (In.} 2 tb.For lei coon%Vella: Inaddition to sending the forcer to die addles in 24n
17-Welt COMMIetlnn mtuhod: strove,also submit one copy of this form within 30days ofcompletion of well
(I c,mrgr.^,retary,r.'rbk,direst prrslr,cic.l construction to the following:
lY)R WATER SI;PPJ Y WF.i.i S O1ttl.Y; Division of Water Resources.Underground Injection Contro)Program,
! 76,'ifi Mail Service Center Uateigh,NC 2764 9-1 6 3 6
1,7a.Yield(gpm) Method of test. It�l/ 24e. For Wa1cr ConWv d•raleeflon Weus: in addition to sanding the form to
Ibe nddress(es) above; also submit one Copy off'this fomr witllin 30 days of
Fab.I)isinfecfinn type: _�� Arrtnrmt conapletinn of wdl construction tothe coon%) health depanrnera of the county
vhnre can lmeted.
+nm,<"W.I North Cnmlinn Dennnment of)—Irrrnmcct:1 :.alley-(,? Diviernn nr Watei Itnsnurcca Revisal2-22-20I tS