GW1-2021-03908_Well Construction - GW1_20210823

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Clearwater Well Drilling
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qREcOR Interrej Use only:
I,Well rAintractor Information:
Well(.'onmaot Naire ft.
0.
CAS ERML
TO
eoorw a- ft.
2.Weil Comitruction Permit M. ft. it. IAN In. Talcum=
Wit ter Supply Well-
Residential Water SLI(shared) 1L our
irrigation ft,
NonAVAter Supply Well.- 011ccovery
Monitoring
'ection Well: it.
Aquifer Stgrage and Recovery
iL
AquiferTest Dstormweter Drainage ft.
Experiment2i Technology []Subsidence Control
Geothermal(Closed Loop) 13TCUCF MOM TO
mt
"da mid Am a
114%1 May Use 111c back of thI paiI to provide addWonal well.4ile details or well
mnsinirtion,only I CT%I.l is needed. Tfldiewo TO'rAL NUMBER or-was construct n 11,jails. you may also I mach addifionall pages if nvetssftrY
9,TbtAl well depth below iand surface: �.j --M-) 24a.E0tAH_W_tM: Submit this form wWn 30 days of completion Of%vcll
Division D(Water ResoureM Information Processing Unit,
If.Statle water level below top of casing (ft.) 1617 Mail&jrviee ibenter,Raleigh.NC 276".1617
a1mve,also submit One copy of this form vAiW 30 dayq Of completion Of wall
14 Well construction Method' rAmstraction to the following:
MR WATER SUPPI-V WFI,Lq ONLY: H 36 Mail ServIc*Canter,Ralcip,WC 7.79;"-1636
13h.Disinfection type: Amount- completion of III CoInstruction to ft county health depliTimclin of The county
where constracmd
Form M_I With CAmlinni7critimmont.of H.",irantnenthl Qicifity-Division vewater ft!"I"I Revised 2-22-201 A