GW1-2022-01026_Well Construction - GW1_20220107

Feb 1519 05;43p Clealwatef Well Drilling 828-622-7241 P'1
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Vt1>C<rL�ONSTRI;ICTIUN ItEGORA{GW]) For intermit Use Only:
1, rllrAntraeMrinrolrmarion:
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` 1 o WATEIR ZONES Q_well Colima m Name rta►ss1 In AESCRMriON _
VC:Well Cnntnnnr l:crtlficntinn Number •�^0(1'1 FR CA$114 ror mnI16-ase'dewelk OR UNM if e e
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Agricultural tmicipaVPlrblic 0
Getxhemull(19eatiag(Conling Supply) 4.
rtidentini Water Suppi} (single) n. - tr in.
industrial/Commercial r]Residcntial Water Supply(shared) m4alkGUT
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�Aguifer Storage arid Recover), Salinity Barrier PRoxrq7ti
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AguhcrTcst 13wrinwatcrDrainage Lxperimental Technology Sudsidenee Contrnf �
Geothermal(Closed Loop) [31race, xt).DRILi,1N0 LOG eB n4ditiatil Awilplfwwury)
Genthennal(Kcatin oo[ingR.ctum) ()ttier(cxplainundcrf121 Rcmuri;s} PRn>R - aimcnimm eater wrlcockifpg arm"ti:r,o�t
9.DateWelt(s)Completed: Well ID# _ U Jj ft,
Su.Well i,oeaHnn: VT° R' r
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C.;natty Pnreat Wmirwit@m No.(PINS)
Sb.t,alihrde and tonhtitude in degrees/raintites/seconds or decimal degrees:
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6.Nam,)the well(s) Permnttent or ©rrempnrnry Mgn fen cenrriat Well CrmtmCwt, Dme
F Rlfming okty/brn+,)herrhV evnIfj:that the twil(W)tear(Brea.)rx,nrmrr.I sl A+oM"rdovice
7.tsthisa repair tn fin existing well: E]Yes or No xdrhl.S.f.'Ft:'rCOW.0100or1SA,YCAC�IC.',1P.00rYaNC'rnrrnrniolrSlnnrlard<mrrt Ohm a
1,011hisarelrain.i/lmakilawniucAdnns+nctirn+irtfn,n+alinnm+dnxl+lninrlu•rx+nu'rn(rhe tn111rnflMerernnlhaehrtnPr01q&d1n the we"IAmwr.
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23.Site rHagram or additional well deails:
R.r'or GcoprafieMPT or rimed-t anp Geothermal Weltit having the same Vim may use.llic back of this page to provide additional well Site details or well
w-nsln+rtinn,only i GWA is needed, hxticate TOTAL NUMBER of�'.xlis construction delailc. You may also attach additional pages if ilocessW
r5:Gl1flj7TAr•,^iTRtICJONS
el.l'olal well depth below land surface: __(R,) 24N, IF'or Afl wells: Submit this form ixithin J0 da}s or completion of well
I yr MUNI k lvedc Ike nl)d!ptht afdierent(nrnn+p&d(nll4(I'alld:(n)1(IO•)
/-•� consiniction to the following:
Ili•Stride watts`levsl below top of easing:......�_SeL „_•_•_ _ (ft.) Alvikion of114ater Reuntrem,information Processing Unit,
Il x nitT invul la i buys c77e/ng,+tar•''•" ,I�( 1617 h1rf1 Service Center,Raleigh,NC276"-1617
I t.13rtrchote diameter: U (ln,) �p 2•Ib.Por foiecHon Wells: In addition to sending the forat to die nddrm in 24a
12.Well consinicllon method: r MtJi,Y l Awe,also suhmil one copy of this form within 30 days of completlort of well
0 c.nagm,rotary.r.,bk,direct push,etc.) a"t—- construction in the following:
'MR WATER----- 'WFLi S ONLY: Division ofVWater Reaourcm Underground ig(ection Control Program,
7636 Mail Service Center,Raletga,NC 27699-11636
tJa.Yield(gpm) t Alethod of test: ( y 2-le, Mir ' t r Subdv 8 iafecHon WeNs: 1n addition tosanding the faun to
address(es) above, also subntdL one copy of this form within 30 days of
13b-- Disinfection type: Amount: completion of well construction to the connty health department of the cnunty
w4nrc aurstmcmd.
i+omi CW-1 i+k+rth[:nmlinn t>ci+nnmcm of tin.ircinmrrtnl Q:eallty-Divismn of water Rasoruccc
Revised 2-22-2ai h