GW1-2021-06856_Well Construction - GW1_20210429

Feb 151905:43p CjearwaterWellDrilling 828-622-7243 p'j
WE�.L�ONS'TR T TIUIY�tECORU fQM 1) For IntemnI Use nly:
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(ir wo11 act one btfloiig(a auiliidcnt) p t 2.Certificntinn:
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6.Witte)Me well nett or DTenvorwy Ri ere aftkrt1001wetlContrneror Date
..��..,,// Ift+.9tf(rrfaJl rhh. (arm,I herrAI,cwfify that thir Wd"mts(W-4 CO"1110M IH 4CVWI l7tY
I in this a repairto an adyllag well: Oves or �pi�lo w+Nr 1SA.tit pC o2l_0100 nr 13A.1K tfC AX.'.OIOD tt'r.NCmulrnaio,r Standardr and rhm.r
"d,It 1c a rgmfr.ft11 Mute +wn nvR.:ansrruconn lrornsatlon G'I71abI lhe"MI,na nrihe Gn!uoftlttr rr'cnnl Aat l'►eNprotvdedrnlhlttucR Muller.
r,xtr rmdv a:l mmy ptatt nraa t/n barkajlAls for+n,
Ll Site diagram or additlotmt well rietoaits:
8.For GeoprobrAMI r or 0md4Lnnp Geotherrsal Wells having the snlue you may use the back of this page tl)provide additionni well site t oWh w well
waontction,ortly 1 GW 1 is rteeded. indiceto TOTAL NUMBER of wells c"triutNsn d'rtals. Yau trrs{y silo attach addititmal ptgles tf nomssery.
driliod: ,_ _ WIMUTAL,,IN3rR MON8
9.To1ar well dcpQt ttdow land surAwa O S- AM) 2y. For AM Nis: Submit thtq form wit)tin 30 days of comphaitm of well
I-At txuL/pfc mrfx I w all dopths f4'ucnt("ample-join rr40;@100) conowAiim to the fallowift:
10.Static tv w iftel h&w tap of tasiag: #L) Division of Water Restawec Inibrmat)on Proces+ft halt,
(,wafer InVI It rthrre MlIng.lac"•" 1617 Mall Service Center,Relelgb.MC2709-1617
1 i.lloneholedfaml tct: 24b,E Injection Welir~ in addition to sandWS the for@ to else nditwis in 24n
above.also Submit one copy of this form within 30 days of complatlm of well
It WOR COMtrttetl(Ia method: 1�-r�-�l cntlstntMion to the fotiowinr,
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Division ofWater Rraaunx%Undeftroand injection Control Program,
FM WATER SLIMY WELLS ONLY- 16M Mail Ser•vioe Canter,RAtelo.NC 27094636
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({�) McthtW of test 24e tllor Walcr SopM►_;&laimHon Wells: In addition to Stmtthtg the fain to
the nddrm(cs) above, also submit me copy of this fomt wilhfn 30 days of
13b.Disinfection type: ,Amo,mt; completion of well construction to the county health depeflment of the county
whwe consuacmd. i
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Form GW-I North Camiimt Deparonent of Enordamrnml Qmtnty-Division oP Water PAW=es Re rineA2 22 Ia1 R
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