GW1-2022-01088_Well Construction - GW1_20220107

828.622-7241 p,1
Feb 1619 05;43p Clearwater W9I1 Drilling
VVEIGL CO SrIC�tUCTION�tF.CORI 19W'�a.1 Far Internal Use On y:
1,Y1r�1wontrattor Information: ----
1✓IY l —-- — wATE 7 Niiti DvSt1UP1tON _
NO." 3n
tVcll Colltraatlt Nainr/� h.
L11
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VC Well Cnntonclar ewifioatinn Number S. lTl ER C 51M11t+ fOt ma th 1' � a
rQ IranM D1A l['JCIr S MATj6a1AL
X 1 Y( ft, h. L' in. V
n:npnny Name. [ ~16.INNER C IVC t1R TIrB G 1hOrma
C tWed I0o
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2.Well Conslrnetinn Permit ft: c )1 J� f7R lY ft 7t/ ff• in. TALCI:NPSS
1.1 rt all applicrrWe well rnment.Minn lr!rmll.+•(Le.flfC:.C.onnfy,SMIe,Krrlancc,crcJ •
3.!Yell 11%(check well Ilse):
SC
Wa ter Supply'1velt: `��it� N O TO DAM _fiffEM0 ICE CHIC 6&S AT At.
Agricultural Mtmicipallpublic U fr. tf_ N•
(3cotherntnl(i.leating/Cooling Supply) esidential Water Supply(single) rt, W
industrial/C,ommoreial Residential Water Supply(shared) Ia GROIri
A RIAL 7iMr !Ra1 D A OUIg1
[tri^allnq - f4 � �1
Yon-H'nfer Supply Well: a ft.h4onitnring Recovery
nja."or' ell: p, R.
Aquifa-Rec[rargc QCroundwntcrRcmcd[atiun 19.$A[unrt;RnvELPnCie It IeaWe-�
-Aquif,•rStorage and Reenver.y []Salinity Bnrtier " COX rya A r LACE"Erg IIiatl
AquiferTcst QStnrinwaterDrainage h. ft. `
Sutwidenca Control rt• rt'
L'xperimental Tcchttnlagy � ,.. .
Geothermal(Closed Lonp) [3T(Accr 0. Rit.Li LOG sitat6 1 rrl kt rat"Ilse.■te.
Cieothennal(Hctuinr aofin Rentm) ()tkler(ox lainundcrR7l Remarks)_ PROW it. fe
t.
A,flareVi'eil(.r)Completed:2_fn i- 0 well IOU
f J ra.Well Lnrntlnn; r'
ftril' .(he,crNamc Facility iDrf(+fgtplicablc) _
$� V, I�t ���f1 Ic
Physir�.ni/A�dAf�csti,City,and Zip
C,nn(y linreel identification No.01141
Sh.Latitude and longitude in dcgrtxshnimitesrsecaads or decimal degrees:
(ii—11 fctd,one lWang is ruf cknt) G l 22.Cer Cation:
ILL 1
6.Is(.4m)the wtll(c) Permanent or 13Temporar,y Sion fire of Certified Well Contractor Amo
,,�/ 1 y 1/mirtg ihrv,f%,rnr,1 he►ehp crmJ,that 1hr a il(a)rmr burr')cnnomr.Av1 in 00wrdnncr
Z is Ibis A repair to An existing well: r3ves or No r•10r LSA tir'�rr:o7.C.4IfdJ m lSp NC.'AC 01C.'.fi?AD fY It Conslrnrn.ur Stnndarda m,d,hnt.t
0"A ix J- n:}rnlr,.rul n,rknooW icell cnnstrrn.Pimr it(rnnnohiatt art' .rpinin ON,narnrr.nrda a ennl,gf►htc areal has been pmtNdrf fn du well owner.
r;uoir under C?1 remark,..rczd4n(or an,rfa!hard•afrhhfjnmt. 13.site diattlram or additional w•elldetaitsr
R.rear GenprohefDPTor(`!need-I nn(►Geothermal Wells Having the same Vou may use Vic back of this pate to provide additiomtf well site derails c r well
txmstnrctinn,only I CT%Ll is needed. indicate TOTAL NUMBER orwrilc constnidion details. You may also attach additional pages ifnecessaly.
drili¢cl:___.._. �. -_- - ..... 3 M 1lr lls`T tGT>ti IONS
9.!fatal well depth below land surface: C 24a. 1'er AH•,We1H: Submit this fort within 30 days of completion of well
b+"r no00pre e•rdr 11u 011 d y,dw riferdreranr fera,nnfR-3@7110'antf;(1ij..10R'l comMiction to the f01101ving;
ill.Static water irvcl below top of casing:,��.t! __—.�._(ft.) Division of Water Resinirees,Information Processing Unit,
ll�'nrrr hoc)l.t Alva cmlnl.tux• •'1 1617 iHLfl Service Center,Raleigh.NC 2'f(►"4617
111.Borehole diameter:0—(in.) 24h.For taiection VYdla: In addition to fending the form to die address in 24a
i2.Well cnnstrnetinn method: f al nve,also submit one copy of this form+vilhin 30 days of complalnn of well
_._.�.. - ----- ....(i c,mtKc-,rotary,cable,6irp:t push,,xc.) cnnshuelintt to the following:
Division ofWater Resourcesi Underground Injection Contrat Program,
fOR WATER SI,PP1,V WELLS ONLY: ^l t 636 Mail Service C.enmr,Ratelgh,ABC 27609-1636
1.1%.Yield(gpm) D Methad of test:—� Me. far Witter,Supply A TafecNon Wells: in uddil.lon to sunding the ibrm to
the address(cs) above; also submitr one copy of this fort within 30 days of
I3A.Illsinfecdon type:, Amount: comptction of%veil construction tp the county health department of the county
where constructed.
Fenn C W-1 North Cnnnlinn Dapanment of Envirdaturt:ral OnatRy-Division&Water Royaurees RevNet12-22 2016