GW1-2021-03560_Well Construction - GW1_20210823

828-622 7241 P'1
Feb 1519 05;43p Clearwater Well Drilling
WELL CONSTRUCTION RECORD{GW 11 Fnr interrinl Use Only:
t. 1l',nntrAttnr Inferno flop:
TO ABSCRt1'{'ION
Well C:onaaua Name
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vC Well Cnntracrat(ettifieationNumber 1s.t�flfsRCASINcDiAMCfGt tL[CKN68S aiAT/mow
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Comp,myName �� -16.INN6RCAl31NGt�R fttRtNG 1ltormaT ljaed-1au D "L...�---..-- traox TO
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2.Well Construction Permit#:
i.frr ail opplicable+ulf martnrerinn parmnr(l e:w ,Gonruy,Stale,V-1-ce,et-) n.
p•, ft. i
3.INN Uir(check wdl list): 17.sCR8 N uuTttalAL
Water Supply Well: aaotbr TO AtNBrr�t at of rptc ess
Agricultural 0Manicipotlpubl'tc p n'
Geothermal(IiCAClllgft'oaling Supply)
i2esidentiDi Water Supply(single) R ft. fln'
industriallCommercial �ResidentialWat-Supply(shared) 1&GRQ1pf To >tirAr6nrAt .R�tfrµo0&AMMMI
te1MIM
lrrl^Dtlan IL
Non-Wntcr Supply Will:
A4anitoring Recovery n.
fnjecton
AquiferRecbAr�c �GronndwnterRcmedintinn / 419.5 � �LPp E hieNMy�tton
Snlini Barrier t_BROM 1AL
Aquifer Storage and Recnven 1Y tt,
o_
Aquifer Test [3St ormwater Drainage n.
Suhsidence Control fL
Experilnenial Technnlopr fill
Geothermal(Closed Lttop) nTfACOr 20.DRILT.iP1G f.00 coact+ r pip toe un
To
Geothermal(Heat Dolirrft Return) Other eht lain tinder#21 Remarks) FRo>R to `®®ft
fr. fa
d,Date WWell(s)Completed: t� WORMYP WellLomfiri
EAVVILA n.
I�aeility.'[lelmer}! �� l'aea1 iDi!(ifApplreablr.) O
ft.
Ph Stir. I Address,City,and yap
�o 2l. ARKS •. � J<,G•l
O
Camay Pareel ideMifleation No.(PIN) �G(C• O
51).latitude And longitude in degrees/minutes/secoads or decimal degrees:
(dwelt fte�ttl�nc int%%n in sufiiefcnt) to I 22.Certi(i ti 1
72` V y 6)ya / UT :w 2
_ tide
e orA SiJatAlArc of Geetlfaf Wel!Commraor
b.is(arc)Me well(s) Permanent or orp r?'
t 1?v s+)ming chic.;+rm,l lirrrhrcvrlfy call!+hr•nvdl(xJ m+r ftrmx)rurtr+►arl+xl lr+a�+M°n C
:,is this a repair to An cxistiag svr31: �Yrs or tjjNo w+tlt fSA ti(,.,i ox.ti or iJA,V(:AC.a2C.'.01D0 Welt Conslrnerinn SYuudarrie mrrf+hm a
!t'tl,Tr i.:r rrpair.fill rnulomnm uvll aoaan,afnn a�nrmatian mid rxpfain tl�c:nnn+rr r+fnc� copy nflim rexrril Aar hpm prolo d In im M:ll molter.
r:rpair under A21 remar/Gr.sRTtimt aronike hi offiitr fame. 2,;-,%*diagram or additiwml well deftils:
),ou may usn the back of dais PAge to provide additional well site derails ar well
R.For G-probefDPT or Closed-ii Geothermal Wells hAving the same conatructinn clriAits. You may also attach additional pages ifncewitty.
constntctian,anly I C.1N•I is needed. indicato TOTAL NUMBER or-''elis
Vq ,�ttt><•_•r-r'Ar insrRLc�o_l�
9,Total well depth below land surface: iR•) 218.EOC.A1L�'t h: Submit this form vdiltin 30 days of completion of well
Far neuA+plewrlLr fit rnl;dtptlerfdr,((crrnr(rtamp/c-3n10(+'atd fn0� congtritCtianto the foliotring:
10.Static WAtVr level betotr top of CSA RI (ft.} Division ofVWAter Resoureos.Information PrOCCOft UP",
tJ'anfrrlcnrlirnhnertcasing.the"•" / 1617 Mail Service Ceifter,Raldgil.MC27699-1617
ti_Roreholcdiameter ll� (in.) 24t,For injection WAJ In addition to standing the form 10 the address in 248
above,also submit ono copy of thin form~within 30 dayt of completion of well
17.Well construction method:_ �L cttnsMLctinn to the following
0c,mege,nutty.table,direst push,ctc.l
Division of Water Reanslrce.R.Underground 11dectioa Control Program,
POR WATER St:PPI V WFLLS ONLV: 106 Mail Service Center,Ratcigh,NC 7.709-1636
132.Yield(gpml iNethod of test' 24c i/or V►eatcr CunQly&ipleetlon R'Nt9r In addition tit somling the form to
the nddr s(cs) above, also submeL!anc copy of this ferns within 30 days of
131h.Disinfection type: Amotmt. completion of Well construction to the county health depallment of the county
where constructed.
Fonn C14-1 N^rfi C:nmlimt>]epnnntent of tin.•imntrtr�tni Qtrdity-Aivisinn oP Water Itononreese Re:vinexl2 2]-2016

Date: 2,
Well Case. Well
Name:
Address:
pump has been installed, well head ready for inspection.
Sign: —
�� WaL Drrul'+"