GW1-2021-04489_Well Construction - GW1_20210429

pFeb 1519 t75;43p ClearwaterWeli Drilling
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1.Wadi ContrartUr I Iformatlon: RV
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2.Well Cordarnetlon Permit A: w In•
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3.Well(Tic(chock tvd]use): 17
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Agricultural 13-Mamieipeftblic p R.
Residential Water Supply(single) M !i
Ceertteratal(14eatingJCaaliag Supply)
indusiriawommetcial sideamw Water Supply(Shama) ltRC1t011T
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Nnn--Vl atsnr Supply Well:
h4onitoring 01tecoverY
Injection well: ft. li
AquiferRecltat;gc QGronndwatetReMedisti[in 19 VRI.I,A a L IIHrtwC ►+�
AquiferSttamgt:turd iZecovcW 05alinity Barrier trllDai
AquifcrTc.R 0Smmwa"Dralmv IL" 0. B.
CXMrilneatal Technology Control
Geothermal(Closed Loop) MUM TOa�Moh spate l
13 Crattkcrmal He i (Retssm) lha( in underA21 Remarks) ft.
A.Dateuldl(a)Completed: l� oC well IDY R. � rb r
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P siml Addmss,City,And Zip N ARKS
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Clunty Pnmal Fdomilicatitm No.(PiN)
5b.Littltude nml(oaloade in degre¢slmimnes/seconds or decimal degrees:
(irwell field,one lat+long in Sutrmlent) 0 12.Certlriention:
Si tvenfpentfioda+dlCaroaatar 0e10
6.1a(are)the•veli(aamnnttat or �e++ Y
).Tv ed i- f a i irle !Well
C cartlfy Mai f!N urll(sJ asps{SrmsJ o"OnlMd'o amr"wr
i.la Ibis A repair to An teoadttg well: �Ycs or �lYo wads).SAI q(,AC'02C_AIOO or 15A W-4C'Bx,.02W Well Coufte"an ytm ditf&+md JAM 4r
lydork is a rgrafr.It'll Mirknawn I-on.wwfwcihw brA marlon plain the mama nrik 4-M afiki,nmrd Aar bdai pr Abd to).!n:well Invlkr.
rr wir MAT A71 rma►kt sw(M eo'rm the harkojlkls jam+. ].L Bite dfaf ram or addidonal vvg dMils:
you may ttse the bn&of this Page lb provide atd181ional well site dahlia or well
8.For GeoprobeAlPT or OuPA-Cellars Geodhcrms l Wtlls having the"me comvVetion titans. You patty aim attach additional pages If nnccesary.
wn!pnsctien,onty 1 t:•1r At'-1 is deeded Indic"TOTAL NUiuIBER of wells
dolled: __ -- (n(� ,.n.,.rr.tt,iP�SiRIICI[ON6
%Total well*pQ 1►eiew land SnrfAcr.„_,. " rD•) A+#.9. Bar a. _ b wells: Suhnirt>his form trithin 30 days of completion of well
RIP Mnloprewrlarch+at"re uj�eruufcx++AR�e-3Cn1T(M'amii�11i100S corL4litlt$iantothefollol�:
111.8tatie water tevct below top of tating: so (ft) Division orWater Romweea,Information ProcWhI y V^
!f n nler Ftqvl la fdvsve car!»g.ure 1617 1Na!Service Center,Raleigh.NG 2'/(d19-16t9
i t.Rotrttolediameter: 1` (in.) 24b. In&addition to toemft the form m 1116 011111400 in 24a
above,Mm submit one copy of thin'u form wi0tin 3o days of completion of well
12.Well antatr"Ann makad: l V l C�C.t� - ru�iction to the foilrnvt49: f,
(i c.mrgc,mtary.cable,0na ptnh,etc,)
Division ofwater tittattur'txs.Undl:rgronnd Injection Control Program.
FOR WATER hY WLY W LLS ONLY: 1636 Mail Service Ceww,Rateiglr,iVC 276WI636
Method of tesC _ 2tm Ror wo cr Sunnis 8+Iait�eHon We11s: In addition to sanding the tism to
13s.Yield(gpat) the adilms(res) above, also su6aut I one copy of than font withinof the my
13b.13Nnrection type: _ ,Amount- completion of%vdl eautrudion to the cotml)holtlllt depattti"
where comuncted.
Fwm C.W-I worth cawtinit Ownnmont cf tinvininvumtal Qrwnty-rhvist'nn cewear PAWMmes RevW 2 22 2A1 b
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