GW1-2022-07017_Well Construction - GW1_20220725

828-622-7241 I P•1
Feb 1519 05:43P Cjearwater\Nell Drilling
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2,NVcll Construction Permit* Il.
;drr Alf npplicnbfa tell cnnctntcrion pamlfGr(Lu f1lr"State ymdancc,ett4 $• n,
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in•jtctiOn Wcll:
AquifcrRcchatgc E3Groundwaterltctncdiatinn 19.SANDiGRAt1rBLPACK 11rEiATIrnLn �CgiNUPITMCr,tOn
S-di waffler FRDM
AquiferStoragc and ReCaWY f3• nv is n•
AquiferTcst �SmnnwaterDtninag4 ft. @• .
Experimental Technology L1NCL
�SuhSidencc CControl{�Ttm'rx RO pRIi. t]'C rtlaehatld�o iTltxr dator,turdw�ra �t "t"it"•`tr'
Geothermal(Closed Loop) FROM TO�
CicOtltcrnini(ticati0 Caoti Realm)
Other(ex twin under ff21 Rcmttrla) ft. tt
t,llatcwen(s)Completed: `W-11ID#
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l�acility:(lat, I c Faalfty[Did(rf. licstblc) h •
ylsicnl AddM-s,Clty d7,ip 21,PE—FARKS V
l0k4fftalion PM
County porcel Identification No.(PINI ix►'�Ig�
it).Latitude nod longitude in degrees/mittlltcs/seconds or dccimnl degre 1 rtffirnfi n:
(i i cwilc�tane 1ntQann is nn4ficienti �� t r.
�1 Dale
em Drury Signal of Catifiat Well C traacr
6.ls{urc)the wells) pmnanent or P
!sv al�mtaP,rh form.I ill inicl�r tltar the well(..)rMr hreral rXNrtrrOCrad M aanrdmrcr
i.in this a rnpralr to an csas4ng w�l: Yes Or JNo x+th 11.f tir_'dC D7C.ofUO or 1SA NC,AC A2C..0:(10 Weld Conslnjrriojr Stondarda rmrf'hen a
rmatinn A",No
mn the nnntrr nrlhc cOP1`"fli�s r''cnrd haehe m protadrvl to tip:well owner.
1,robs,•sdrep4irfillaarknownivelleo-Intcf8mir�n Pr
r,wir under Alt remarkcc serf/mt nrrmihl:hark nflhisfam). 23.Sitc tSngram or additforml yell detgilst
)tou may use doe back of this page to provide additional well Ahi detail9 or well
$,For Geoprabe/111PT or Clwed-lAnp Geashermal Wells having the same canGtrurAiDn details. You tray also attach additional pages if neccssnry.
txnslnictinn,anlyl CNV-1 is needed. rudicige TOM NUMBER nfuclls
drillul:�_ t1RMITTAi i1tiTRtiCTiOLV°�`
9.7latnt well depth below land surface: t�•1 elf 1. Isar nN_]trsiLa: ^-uhmn this form%vithin 30 dikvs of r-ospicdon of well
1%nrnrtrDlplevegg list trlidiprfa.-jdijl'arent(ezampla-a@((2owT,,nd<Qlao9 Con.WUCl1O11to the fltll0lN'LIg:
10.8tefie ivatWltttt:l below top of rasing:._ 00 Division orWater ResuureeSs iuformution Processing Unit,
1(waprr irru!is rrhnne Carinjl.eye t 1617 hItdi SeMve Center,Raleigh.NC 27699-1617
ti_Rorchotediinmeter. —frn•3 24 r �t■h'cfion GYetts: in addition to sending the form to the III in 24a
above,also submit one copy of this form within 30 days of wmPletlon of well
l W 11+elI construction method: ` cunstr,tt 6011 m the fof)Dwing:
0 c.angc-,ran'.cw*lc,diV4%t push,Qc.l
Division of Water Resnureca,ifndergronnd injeetiun Control Program,
WA WATFRSCpPJ_V W.LLB ONLY: 1636 MaitServlceCenter,Ralelgh,NC 27699-1636
13a.Yicld AI Method of Iasi! 21C. lint V►lt t�n1►I1lti Fat log Welty. 1n addition to sending 0 tors to
(gip ) the nddress(es) above, also submit one copy Of this form within 3(}days of
13h.Disinfection type: Amount completion of well crKL%UUction to the county health department of the county
where consttncted.
Fornf Gw-1 North[Amlinnt;cpariwent ReviseA222 2016