GW1-2022-09671_Well Construction - GW1_20221027

Feb 151905;43p Clearwater Well Drilling 828-822-7241 P'1 .. .
WELL COIVEW&TION RECORD{GW 11 Fnr 1wernnl Use nly:
1. .1 fnn tratlar Information:
� f%�J "�"� ,-- AT ZONES
'77iAy1 TP )vim
Well Convarlor Name
VC:Well Cnntr+gor ratification N,rmher ,RC q]ING FbT11149I W11111111tpitLfVER
t -irROAt rA IA 171i t?as M IMML
I:.n:npnnyNnme
_ t� � l..l�l_J� BRC iNGORTI DUMCT���+*TAt NA'ETNIAt.
7
2.1Yet1 Coaatruction Permit#: a? rt In.
i.lal all ryr/»icehlc wcllmnrrnrralan pnrmltt(La lA( Cprrnly,SIa1G Yatrirmcs crrl
3.,ty dl flip.(check Ivell rise)_
WAtci'$a IT.SV N ra,CIWRLB AT L
PP �VCII: IrAGM To A
Agric llttlrol FPML4
tmiaipollPuhlic 0 41_ ft_ b+•
rAquiraStorago
crmal(Eleating/ConlingSimply) identinl WmcrSupply(singic)
idal/Commorr:ial idcntial WaterSlrpply(sharad) g, auT
UNT
tion t MA L 6�,PLA B as us A
`nlcr Supplrt" �'toring Recovery fl• fn,
nWrll:fcr Recharge Doreundwnter Remediatinn 19 SAAf111CR+lt✓BLraStoragcAndt;ecnvcr�' r3SMnityBnater papa[erTr_ctrimental Tcalinolrrgy 05ubsidence Contrnt A.Tra ct 2Q DRII.1. G LOC cmal(Closed Limp) p sap, ■tc.ermal(Hratinsumling Retum) 0 Ulher(ex lain under of Remarks} FROM
` 2 fr, �iL
f,i?aac Wcll(s)Catnplrtcrl.� 1� Wctl 1AA
/ �- O it. I tw •r
5n,Wr 1 i.ncati n--� �� �V�-rC--t 5 V IS D ..
t 9- It. tt. l I 1.,
l�:rnlit}':fJntrerldame ..' � /jg � � �nn'Qlity�[Dii(if�apt,l�icja(h�tr.5 � R' R" .. _ _
1 1� � LIrJC..i �. rC"`�rn�'^-:__���1-y�'�3L�� �• � ..��(...d i� _ 1 t'� v. •
tv n
P iral Aridren City,and Alp71
1
•2t aEMARI{S
Comrry pasaeltdcnsiltcntinoNo.tp[Rlt IRr.,r.,z,.4._ zff6w�:,3 Urtii
5b.l.ati fall P,and lonA,ltude in degrees/ini notesise ca ads or decimal dngrces:
{"%MI fie 1),One Int9nng iasufncicnf) Q / ification;
4".1 arc)thewell(s)KP-1
aneat or ©ITempnrsry Sion hrOMMIiCANVetlChuUmAar Doge
!cu,rllmtaJT Ntn,Hrrm,Ilre+vjvr�r*+fjrdorrhr nrdJl.)n+n(xm-1 cm:vmrmr+jn ocnrdnncr
7.t1thiaarepalrta am exlYting>4C11: D1fCS OT a 1111Jr/SA4C'AC:p2r.4�ODnr15AYC.1C.11?r'.pIODR'eltCatrrtnreNrorVamlardcn,drharn
I71hr••ieerrc(mir.J111nutdttnwn,vcllcnaxrrncrlwrirt76rmatroa��,wv plaiw Ilia lNnuregr1fru •M+Ynfl/r.+.etecnrrl/ioshrotpMt'ldi+lfMrlu!williMvrrr�:
r'•'.prrlr render,�2 t rumarJcr saci/on nrfir the hock of fhlx.fnm+. 1 .*lit--dbgmm or adlMdo mt well details:
R,For GeoprobeffIFT or Oosed-iAmp Geothermal Wells having the same you may use[Ire back of this page rn provide additional well silo detnih or well
MT1817,11txion,offly I GWi is needed. 1'ndicatu TOTAL NUMBPR of cunsh7wion details. You may am attach additional pages if naxssaty.
ry.Woral well depth holow land susfhee: � `�� (tt.) r4a./or�tl Welts: Submit thin form within 36 days of completion of.yell
1%nr M11NPlc 1PeAt1 t ali d!prAr rfdjAcranr?v.rZv -J-d W0 'arid fOrlI constniction 10[be rW OM111g:
111.StAtle water Iemel helow top of rasing: (ft) Division of Water Resources,Information Processing Unit,
1J'1rn14tr1prc1 is Mipe Cnsing•t•e t 1617 r4oll Service Center, [eigb,NC1769�-1617
i
ti_iltrrchotedinmctcr: (in.) ?.db,Tiar Ittiertian Wills: Its addition to txrrong the form 14 diq Worm in 20
11+e11 eanttrnelinn methndt shove,Lana submit one copy of this form within 311 days of eompleslrm Df well
12
fi c.Well mrnsy,eobtc•direct @rill,cie y construction to the followiar,
nlvhtnn*toter Resources,Underground Injection Con[rat Program,
MR WATER SUPPL Y Wf`FLL,S ONLY, 1636 Mail Service Center,PAtelgb,NC 77409-1636
last.Yicld(glim) ✓ Method of test: late,it Wgtor-SunRIv&KIlkelion Wclirr In addition to sendivg tht fbnn to
Me nddras(cs) above, also submit oac copy of this form Within 30 days or
tab.Dkinfertlon type-- Amatrnta completion of wdl canauuciioo to the cormiy health depanmont of the sound'
Mrhore coaglmcted.
]torn)GW.I Nott],C'amlirmAanonmeat�ften�rainmeatal Qawlrry-Awisrnnnf Wwrr Awomcea RnuraeA2 22-211t 6

i
Date:
Well Case: Well#: Z()Z Z _ 000141
Name:
6
Address: ePb�d Laluz-2 ,
Pump has been installed, well head ready for inspection.
Sign:
G wafe We,W Dri,(,( A-tg