GW1--04147_Well Construction - GW1_20230623

Feb 151905;43p CleatwaterWell Drilling 828-622 7241 p•1
-1ELL Co LRuc TON RECORD(IGW4I Forintcmn)onoan y;
i.YV Cwintt'ite In ipn• ,
L/l 1
h NUM -per ,
Writ Condsgot unit -ft. ft.
a \;6-A .
VC:Weil CnrereclwCettiflcalton Minterr tt tlbe1
Clieurwouici Well OnNnoi. . 12r
lnaapna}Nnma �)NGti _{�tothir.iikl
� u*tR'�7► itA�1t.
2.won Commotion Permit th 1�a tna o tn.
List all ap lica itenuifc imntellatiparmIts(J.0 UIC,Cooly,1S1al4 ran'IA+rvr�)
i,- a fs in.
3.Wen liar:(cheek well met L, .-
V!'ettr Supp(it Well: 1761
,nail CO • MAIM* SWUM i--TilicKti n sting AT.
Agricultural DItifuniaipol/liiiblie IT 6-I R- D.
I Ocrincnn8 (LicalinglCoo.lingSupint midentioi Water Supply(single) ""' i' a. In. I i
TM tndt191fieilGonunetajA D csidcntial Water Supply(s<taron) , okp)re , I
To ter+ 1 rtr r�trLgAw¢t+fottor
��ltdgntian (, . f 9La sx�a. (��(� l Sxev+/� t o Cl
Nan Wntersupplyweli: - �
A A40nito' , QReutwory a R
An el: — ft. tr.+ I a
ilil Aquifer Recline ElOrmindwatcrRclncdistian fi3 SA M R VRLPitC Imo
}*1 Aquifer'Stomp an4RecoVery DSalinity Brinier Nam _TO (ttmm a_,;e. • .
a AquiferTsct fSumltwatcrDraipngo I a tr-
VI i,q,erimeatal reele olontt EiSubsidenee control O. I & .
II•Gcothannal(Closed Loop) la7knem .0 01.00( ., - •a►i::- -_, tti>. ' IL
11 Geotilamnl cathilFoOli Retinal) (explain Z ` �► 3:�' '..,' ' .>crw�ra)ilia liter era t undor1 Remiuks /' te r -' '
I.pateWell(s)Completed: `2 ell MY - Z 10i .__-
` Z0 '?p3to 1, '/ U.1
S .Wen Locet)no: � -
Facility lose;Ne mo . Facility al(ifepplleetae) O. R' Fs
'1 ma.' r�"-•a'+ �"' �*
2 1fra.i. Q �ma.'A ,Cbg,end?.tp i l �t6lNt►RtL4 .J[,N ,Cl 3 2.923
ODD .
JAct
wauy Anal rdowtfietlret,Pia(P1At) - ,, 1n�..'�..1 t„,..prr..„.„..,3 I to 4-
DWQi OG
5b•hatitirdonoti lonplititQliisdcgreeslminuteslsecoedsordecimal drgrec
Orwell hold,one taNanitis Aidllcient) a �?.t: ttont
' Sz' 131 a,�Q DD w�- 6 - 23 -23
es.Mors)the calks) Pa-maw or EIr1';tOPararV tiiaaltA►etiCtstrroaar Deft
Ib Moog tholarm,I hn�hrom!1 Ara i1 r,ndn'(s}I 4Se+eruj cowenve�,t in cenord are
',.LithisarcpulrtntmetaitittgwolP )YOI or No umh114liCAG42CA1UOOr1SA??1 ACt11C.(IM Well ConstmtttotStotdmrss mot Am r
ifO,J.v is rrltain,(N1 outhnor o well otaun coon mfr»wrtnndm tm.It2 Baum!.:Tiby ri'PY ojllJlF rernrAkas?�aal providedJRrbewrdl Awttai
c aeirrmdeokW rrmnniasr 1140oPonthe?ladeltbisjoml. l �q(�;
a'k..Bitn+thgstim or
8.fror GOO1Wabt/OP I or Cloged-L onp Geothermal Wens booing 1 S:tine Tau may use the bock of ltii4pe»a To ltrovldeIIddltlowil w fl site detainnr well
onnonicti nt,anlp I ow.!is modal, lildfcnie TOTAL NUMBER on mns a+it9trurtinaddaiis. YNt ttlttp also MSc!)addltinnel mom if ntoitEdiatyt
drilled:,-. ,..ti .... _. . .. ..- 3L1 S 1ikMMJIM
Teem'welt dcpi i Merv,land ret riecs: J 1 for All Mtlls: Submit BNa form within r
days of eampletioa or well
1romilaplc wear littatldoloripeal!fataapla3@l0(eang MUM tonsnuctiontotileli OIR:
l0.Stadio twdeoterocl balm top of ming: (It) ))iv d a of Wuter Resourers,In1 tIIUtion Process Ludt,
{/ram. m/Is idiom caring►Bet; "1i 1617Mail Service Center,Reldg$rr NCa7699-hill
11.Doiehotediunattr (in.) 2Alb prtrladmilep jEctlm in gallon to rending The fonts tole address in 24a
f'� ����� // atom tato submit one copy of ibis form within 130 days of camplada►of welt
t211►cn earltltrgatlprrigat/od: t V�tX.v`�t constructiontothefolinwing
(io,nos.,ranny.cable,dolt pub,stet
..,.— . ---a. Division orWiter Rteciu nee Underground lgjaetlea Contra)Propane,
yOR WATER EVPPLY WELLS ONLY: 763b ttinASeardoe Center,Reletsbi NC'd91A f636
Lk.Yield(goo ' 0 Method or tests 24e,tray Water SD®tY it rpteatton Wen tooddidea tranundlog Om ARM w
rite Rddre s(cs) above,also submit one copy of this Einar within 30 drays of
13b.Intsinrcerlon tp ,Am lt oua completion of well commotion to the comity brtalth dt!poflment Of the county
whom coneneecte ,
Frei Mat WACmntitmfepnnmenteNino&oanuatraQnanty-Didion ofWarnEmmas Rovreedz 2x 2016

Well DrillerSelf.tireut Certification
Owner: Lewbn ThOrnC6 New Well:
, Wean I Zr Shalt . fir: �.
permit McWrs
I hereby c r that the above referenced we11 was grouted in a ran©e in ••,, with
all County .
Wren Drl m Rek Meadmos Spark
CertiScat#: 2 l l�v - A ba Groutad: 5"23-23
Construed= Grout
Total Depth; 3 4S Type C-Onga
Casing vc Thickness: tom► d
Casirg Depth: q Depth:
Diameter: 1
Weightfibicle
Height:
Drive Shoe
car; 1r> .�..�.
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1