GW1-2022-01008_Well Construction - GW1_20220107

828-622-7241 P•1
Feb 1519 05,,43p Clearwater Well Drilling ,
WELL CONSMCTION MCORA fGW-11 �Fnr)ntcmni line Only:
1.Well CAnntraetorr finformation:
14 W Zt)NES ----- _
off Tn DESCRwrioN
ntra
tVelt Cocttx Name ft.
ft. n
NC:Well CnntraelorCertificatinn Number- -is.OUTER CARING(liar T 110-tatted arch)ORLiN= a e
^ A — _ `• `�� �in' pTA1ML?LR 'rlll[]tttBBS MATERIAL_ l/i)l.Jil}Yt�1YY w `J Y 1 t it Y.✓11 n. 2"� Ct. �• in. � V
Cnmpnnv Name rh� -. D01 n/ ` ��6,LNNBR CMIIoW OR 7lwir, thorwel elweAaoo
2.1Ycll Constrnctian Pctnrtit#:_ D� `(�i rnmx To ntAatcrra+in Tntcwa' S NAtFR1AL
OW all opplic»hla well annwntcrlon parmltr(i.e.IM,Cminly,Slalq I arla»ce•err_) N• _
�.• k, in.
3.Well Use(cheek well ust):
'l7.SClt$ N
Water Supply Well: � H r� ntAnrstrsla ararsys rntrlwttas Tsaul.
Agricultural 0Municipallpuhlic O ft. ft. in.
Creahcrmal(FIcating/Cooling Supply) identinl Water Supply(single) ft. ti in•
industrial/Commercial tal:idential Water Supply(shared) •-18 GRol 1T
1rr1^alien MR(1M 70 MATERIAL 6MPL71C6ME.`(f?1ci77tODkAMOUNT
r
'Von Supplvwrll:
Monitoring Recovery
injection We91:
ft. R-
Aquifer•Recharge E3Gronndwatcr Rcmcdiatiun 19.SAN111GkAVRL PACK iia ble
.Aquifer Storage and RCrovery DSnlitlity 13a ricr FROM I HATIORIAL CEMIiNT ML77tOn
AquitcrTcst 13SmnnwaterDrainage-Il n n•
Experimental Teehnology Subsidence Control fl. R
Gcothennal(Closed Loop) [)TCacer 2o,DRIi.LINC LOG rttaeh all al iVAMN
-PRC)R TO D eaktr.lu rap/retat ralna eta
Geothermal(Heatin ooling Remm) ••1� Other(explain under N21 Rcmarts) tt. It- 5- `�-
d,tlareVlreq(s)Completed:?- ,c�•l weil loyfin)
Well/,nrntton:
o herd ft.
'.tcilih.ChmerMarne Facility INI fapplicahle) R• R-
Kb
&ysipnldrtrccx,City,and 7,ip ft `
21.REMARKS
County Parcel identification No.Q N)
Sh.Latitude and longitude in degrees/minutes/seconds or decimal degrees:it well field one tatgang�a sufliefcnt) b /,, ;I' eMificntion:
�� N Die LQS w �_I -1 -4
6.Narc)the well(s) ermnnent or ©lfrmpnrnry Signnrurr.nfC.Mi r ell Cemtmetor Date r
lev n ming dox.;nrm,1 herrhp varrlfj:that the nv:11(.j was(Wirv)t7Xltll mul M 0"Wdmrce
�•14 I1"a repairm an existing Well: Oves or �No w4th 1-1A JFVC'X'D).C..?10V or 15A,YCAC OC.0200 well Consfennian Siondarde and Main
f'lbfr 1.a M—ir.fell anrl710Km It-dr.m.5irncuoa lrlforrnalinn a plain dKS,xrnac n(rha [npp gfdt(c rrenrrl hat hRdf/IrAV(de'Ala llu wr!fl nwttrr.
ragnlr under s.'l remnrkz.rcrtlan fir errrhr,harkriflhtw.foral.
13.Site iliagnm or additional well details-
8-For Gt»probetOPT or Closed-1 anp Geothermal Wells having the Same TOU may LISe the back,of tl1iS page to provide additional well site details nr well
onnNantction,only I GWl is needed. i'rtdicaw TOTAL NUMBER of-.ells consttuciintl tlrtails. You may also attach additional pages if necessary.
drillui:
9.lrotat w¢II depth Now land surfncct J __(R•) 24 for Ail We11s: &AMit 00.4 form within 30 daYs of rnrnplelion of well
w l rr""N'Prr, ens list sli d rprlar ifrJi�'er ant(esampla-3n1aP"and laa1 construction to the following;
In.Statie water level helon top of easi ng: (fr.) Division of Water Retttntrem Information Processing Unit,
1)'Malear Arcl Is rah me Cming,HAV..,.. 1617 Mehl Service Center,Raleigh.MC27699-1617
11_%rehotediameter: l U (in.) 2ah.For t_ w�ikon Weps: h)addition to sending the form to the addm7s its 24a
I Welt construction Method! Cut alcove,also submit one ys co
copy of this!form within 30 da of completion of well
�-�=�----—---- construction to the following.
0c,nU�C.^,rnhlff.4]t.1C,(atrCt;t plt5il,L'tC,)
InOR WATER St:pM-1'WELLS ONLY: Division orwater Rrsources.Underground Inflation ContTul Program,
t 1636 Mail Service Center,Ralelgh,NC 27699-1636
13a.Yield(gpm) V CJ1 Methad of test: 24e. For Witter SSunnly&Falection Wells: In addition to sending the form to
Me nddress(cs) above, also submit One copy of thig form within 30 days of
IA.Disinfection type:, ,Amount: completion of%veil construction to the county health department of the county
where constructed.
Fen»0W.I North Cnmlinntacpnnment of tinvimrimcnt.tl<0113111y-Divis,nn of water Reymtrcec Revisal2 21 Znl R