GW1-2022-09894_Well Construction - GW1_20221028

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Feb 1619 05.43p clearwaterwell Drilling
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C,unly Paul Identification No.(PINY
Sb.Latitude and longltude in dcgreesh116MAI.Slsecnnds or decimal drgreas:
(ii avett ficLt,one latrlana is sutiicicrd) u 1 � e 'nation:
t�1rr• tatifiJvl Well Contactor ------ pale
6J.is(are)the weil(s)' ermasent or w.Il'emmOW I1Jerrhv real :111a11hr n+dr('J MW(K'a=)�MrW1 M aunrdxIce
a Iry arlrnrn$rLfs_(orm. (1
u•rth I SA ti(.:JiC'oZC.0100 or 1517.VCJiC a2C.'•(1=0D R'eQ Cunsltrrrrian St Wards rmrt rhat R
7-la ibis a repair to aft e3 istiag well: Dyes or No tip nflhts r,l d ff i hachr1)o rnt+ldad lx D2C.itwrlrx.
!f INV isy rtyrair.flit antlmown,tvJ1 enasrrrJcllpa b fonnailan 1 rapfairr the nann•e afrlrc
repoir under A21 rcrporkc smIlan nrmrtf!hark afflrrs•tem1. 23_:3Itc diagram or additional a'cdtdetails:
i'AU may use the lutck of This page to provide additional well site deiriils or wall8.Far GenprabeMPT or Clased-1 cop Geothcrmnl Wel{shaving the sable c1)oatrudinn details. You may also attach additional pages ifneceasmy..
WT1.91ntetion,anly i CrW-1 is needed. rndicato TOTAL NUM+ BER ar-wrolls nenrrrrAl lAfifR IC i1QA1$
9.Tat'al well Gep it oulow land aurracct Submit dtia form within 30 dads of compiC1101i Of well
lacrnurDiofcxrtJrtl�rafd.,rhrjcbifcrmr(rrampla-3(a?tU�'andc(alfR6� con%Tnctionto the foll"ing'
10.Static writer level below top of casing: (R_) Division ofVYater Resourees,InihrmtrKon Processing Unit,
If mlerlarrl isrrbnvecRs/ng,vac"•" 1617 e9>,il Serviec Center,Raleigh-NC17fi99-1617
{]_{lorchote+linmetcr• Cin•) ?rib.Fnr tote tion lYe tLs" In addition to sending the form to Off;pdtitcxs In 24a
above,also submit one copy of this form•vilhin 30 days of cam pltKltm of well
I2.Well construction method: cnr>sttuction to the following:
0 C.ouge-,mums.cubic,dim.%push"A") Division ofWater Remrem'Underground injection Contnd h0graln,
RbR WATER St:PP1_V WELLS ONLY! Ir1M Mall Sarvire+Ccnter,Raleigh,NC 27699-1636
_ _,� fi4cthod of task 2.1c. fear Water S- .&TnF-Mfi#We11s In addition to sanding the form to
13a.Yield(gpm)
the addtess(cs) above, also submit one copy of thin form aiiiiin 30 days of
ran.ntstrrreettan type: Amount: t*mptetion of,vdi consUuchon to the county health department of the canon
where constmcted.
VarmGW-t NaAh4Cbm1inn0epnnmentofr3nl-WTI ren0Qrratity-Aitisionot.'WaterRcyouraka RevAwd2-2226t6