GW1-2022-09839_Well Construction - GW1_20221028

Feb 15ID05a:43p Clearwater WellDrlfling 828-6227249
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b,ls{are)the wei(s} Pcmmnnetie or �iTetupnror}r S of Ccritrro Well Cantracwr Date
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7.is this a cepa[rta an cx)sBn>;wdl: Dyes or No. H►ih l i r 4CAC 02C.0100 or 15A AVCAC 0t7,I20lViell Comlrnrrrorr9larrrdards muf)hm.r
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23-Site dbMm or ndt8tiannl well deeds:
R.For Gcraprahe/IIPT or Clamed-Loop Geothermal weiLi having the:satne )'au may wo The bnek of this page to provide additional well she demils ar we.11
unnstprr tian,ant)'1 CrW-1 is needed. 1'rtdicata Tp't At.iJUMBEit of urlic conantetinn details. Yea rnayaiso mtacil addidanst pages ifnoerrssnty.
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9.TOW well deplh bataW land surface:
r:nrrvvl6epre.wJJs J::e..JJdy.q..r fis��m.ry•.�a,rPh»a�i.Tgrr',arrrtc(ae[rxr7 �'-� ) �' ED matt wata. submit Rik fame I,�N.�0 olds er complelion of•vel/
O conwMion to the folloting:
i0, ierla id1vflwAftrrevel bell"top OF casing: ( ) Division Or wh1w Resinireca,laibrmation Proe+ming U04
{(rnh'rdanllrtrhnvo cgrYng,reae.".^ G 161?IYIra9 Sarvice(:eDtet'r fraWgh,NC,7k99-If►17
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/n� t / 7,tb Fnr bticr„�tioa�ts: In addition to lxttding the foah 10 urQ addre�in 24a
12,Welt cnnstntenan m01ham MLO-�y nimvr.,Oita submit one copy of this form within 30 days of compiWMt of Well
(i c,mlilm-.mmry.mblo,direst panh,,tr.) cnitsicaetian m the following:
mlll wn rEltRr:PPtLIi w>cLLS alwl,v: i)Ivislon of Water'StlilnttreR,Undergronntl ir�tletion CRntrm Program,
I16361Hof13arvice Centers R41e1g1kriWC Z769MaG
1.3R.Yield(gpro) Mefliarl of test: t 2te Itnr Water Snnniv A� Fallon W��,in addition to soading the form to
tie addmss(cs) above, also submit ane'copy of this tbtm within 3(1 days jr pisinfeetian type: ,Amount: completion of wen conswedon to the c9 mfy iWlh department of the county
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