GW1-2021-04019_Well Construction - GW1_20210823

828,-822-7241 PA
F eb 1519 45:43p Clearwater Well Drilling
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Aquifer Stprape mod ltccovcry [33alinity Barrier _ tx n.
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I�xilit►dOnmer Name Faelity IDil(ifttnpl)agble - !t.
Plivsic,tl Addrm,City,and Zip 2t, AR
Parmlidontification No.(PIN)
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—.—Ir raider All remarb wxtim aron tfie eork t f this filim'. Sim tgoRram or 144111oml Wilt dam: �flg m rasp
You matt ttso file bosh.of pus page to piovldo nidditimlel weir sire
R.For GeaproCefDPT or Q wed-t.cmp Geatbw ail Werra hoving fie-spine G>A9lrurai�drtnils. Yeu nmy also at�eh addi�anat pates if noecom
txmsFntctian.onty 1 OW-1 is needed. fndimil TOTAL NUMBERofwclls
9.lrl)tat well depth fRIOW[Find Sadme (R•T ZiIR. har Alt Wes: Sttbrilk tftis lbrm wWri 30 days of campia11011 of well
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i i.Rot>•hoic diatncrer: w (tn.) �+bfi For 1n add Lion to sanding the fop"lD*a adlimm in TAn
f n� above,FAW submit one e of this form within 30 days of 01111 lt3lott of Walt
17.Well mubtractton meteod: __- t _ c�rnsicoctioteto the fafttnvin�
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mvlstott of Witter 8raatttses.Uudctrground tgjeetion Coatral Frogratn.
IN)R WATER gCPP_'V VVEUA ONLY: teas Mailserviee cer�r,tmteto.HC 27091-1i636
G wthad of teat: _ Itor Wafer 4nQa1v&i(ptMHor We1R in addition in stmding the Omn W
1Ja.Yield(Rpm) the oddt'fss(cs) above, niso subet h om: copy of tills foms within 30 days of
Amount. completion of:vdl constriction to the comity health depaea M of tilt:cwM
t ib,Disinfection type _ whore corm tncted.
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