GW1-2021-04560_Well Construction - GW1_20210429

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Feb 1519 05:43p Clearwater Wall Drilling
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W EILL CONSTRUCTION ItECOR�(GW x� , For internal Use only:
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Company Name _6.tirrtsn CASING OR rvalwc t >tr+
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s.Well file(Cbfttd+rd)Ilsc):
WatersapplvW�l: to r., atx Talc e®et w.
Agricultural []Monicipaftbkc o R R•
15eate,ama1(19eatinWCtae Ung Supply) E3Restdent11al Water supply(single)
(ndus1riaWonamorcW oRaswenrial Water Supply(shared) lg, iIl
infl atioa A L
NOR—water Supply well:
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Monitoring Rccomy
injection d: ry. R•
AquiferRecl►agc Dc-mindwaterRcmcdiatiam 798 VBLPA a tde
AquifcrStgMAC an4 Rexovery Dsaibiity Barrier PRO t. tenrrrw MCnroo
Aquifer Test astonnwmaDradnago n n'
raperimental Tedinoingy r3sumdcnce Control f►- B.
Geothermal(Closed Loop) C ch
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Genthennal Haetin t' Reh.) er( inunderP21 Remarks) Q tt. ea V
.t.Date wells)Cerr Vlete d.I LA-10 wall IN It. rt. d
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Sa.Well Locating:
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racilily7hvAcrNamc Facility DO0fapplieWc) n. &
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r mill Add .City and Zip� 1v �t. ARKS
cmuty Pnml idmniftcatiem No.(PiN)
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7.is Phis a repairto an existing well: oyes or C; V- pdrJl ISA,ry7'pC'A2C.?100 or 13A AYC.AC.02C.0100 Well Camtmdial,Mofthn*mil!Am Ir
MrJdr A.�rgnlr.JiJi mrrl„axm wrll.�r+.unxram ir�nrnia/laa oily rxplain the amurc n(�JH: �Y nftltfi e:rxrmt pus hdla prot�erlrn flu aorll ntvgrr.
rmlrneadcrG2facrnnikrsrz(imtnrrarr/rAetrkoflhfsfomr. -LL sve diogramoradditionalwdidIGtlINs:
8.For Geoprotu/bVr or dtnsd4Anp Geotbcr- i Welts having the sanle 1'ou may use flit tack of this page to provide additional well site details or►Merl
nnnamction,only I OW-1 is need e ,l'ndirsto TOTAL NUMBER ofwcils Ci1R4 joodtinilc• You may also aftach additional pages If rltxeas 4.
drilled:
9.'lrAtat well dcptb bdowyd surface Pt) CIA.hr AN W lk: Submit this form wits in 30 days of compiclion of well
Par rauldpre wrllc llse aPdgdbr ifda drum(rtampAr-3�fi1Jd0'atdFQ+110t➢'} Cnnstrwaian[011ie foil ft
16.Static water trowel below top of easing: (ft:) Division or Water 111001=5,1x%rwatiort proeas ft Urdt,
U'-fer Acn'ef it Am cwrW.ere I617 Malt Service Center,ILddgb.NC 2760-1617
11.Bonehotedrameter: (in.) 24b.For lwlcetion W" In addition to onding the form to die address in 24a
above,also submit one copy of this form wli An 30 days of earttples:laa of well
12.Well amttrnettan method! corasfrtataion to the folltming
(i c.mrgdr,mrarl,mole,term finish,sec,) I
Division orWater RrMurce&Underground Injection CoRwol Program,
FOR WATER fiitTMV WELLS ONLY: 1636 Man Service Cart�r RAWO.NC 2709-1636
I32.Yletd tppm) Methad of texh lac.,far Water Snnddv&fnieeHon Watts• In addition to semdiag Cite fam to
the addrcss(es) above, also submu me copy of this form wifta 30 days of
13A.Olonfection type: " Amount. e,mptelim of well construction to the county heeltb demn"vent of the County
Owe eonBtltrcted.
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