GW1-2022-09805_Well Construction - GW1_20221027

Feb 1619 t)5;43p Clearwater WellOrilling 828.522^7244 }' P 1
WE)`.L CO T1S tUCTION RECO". {OW-11 Far internal Uge Only.
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hermal{[leatinWcoating3uppi-v) Residential Water Supply(Aliglo) ft. to ia,
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this a repair to an exiadng welt: Ves or lVo u lrA isa k7'.er.nzC.�1roD nr Isa.vCAC o1e.',nln1 a'ellCa»srrnrnmr vmrdarda anr!rhm.r
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23.Site 10aReam or add)tlotmt well delatls:
8•For GeoprnheA)pT or Cloged-l..onp Geothermal We%having the same You may use tilt back of this page to isrovide AddRionid well she debills or well
❑rinSIT"Utinn,ally I CsW-1 is nerded. 1'ntlicnto Tp"fAL NUMBER nf�.cltc t nastntetian tictAi►g. You laay am altiteh additional pares if necemry
9.T'DIA Weil dopih below lnnd surlkcc: __(i�) yl,s,�,,, ,gyp w.1ls: Subtnif this foam within 90 drWx of cvmprclion of.Fell
1•��arrdupre.,.,,r,;,r�r�AIWA•trayl-�,rar 11;=ap,�.fJ�n�olr•anrr lno� i congtruclion lathe follo►ring:
1n.8tatie watop levRt below top of casing:lQ0 00 Division of Water Rfsouraea,Information Proeening Unit,
!f xnh treho ediatn tv.r 1617 MAR Servitc Center,IRdelgh.MC3761M-1617
1ltTrchotrdlamtter: {in.) 7ilA -m FxJR0lQp JKcn- In addition to dmiding I)le fort to th4 addrees ill 24a
l2,Welt crmatnreilon method: Ira t a•y u rdtove,alto submit one copy of this form within 30 days of completion of well
(i c,nuaar,mhtry,cable,direst posh,c'lc.) construction to the)'ollowing:
" WATCM SCPBT,Y WEi IA ONLY: Division of Water Braourm.Undergironud injection Control Program,
1636 Mall StrvlrA Center,I RAtclgir,NC 27694-i636
13a.Yield(.pm) MONO Af teat: IleG Vor Water Spnniv&f0feelion VAlp In addition to sanding lht form to
Me addrtwss(cs) above; also submit one copy of tilig form VA11tin 30 days or
13h.Ilkinfeerfaq types Amount., Me
of Well constnxdon to the county health department of rho ceunly
whore coastmemd,
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Date: L9 - CD � �a-
Well Case: Wellft 001 - 0041 �
Name: VL4C C-he-S lONI L��,t drn� `Gt S kiCkuC
Address: I\AAL -
PC,,r 5 0 -' Cie,Cee-,I(, .
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Pump has been installed, well head ready for inspection.
Sign
C.ea,rrwa4-&rr Wetk Urri, kZ*%6
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