GW1-2022-01103_Well Construction - GW1_20220107

Fol) 1519 05;43p Clealwat©t•Well Drilling 828-622-7241 PA
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Agriculhtral tmicipaVPtthlio -
CrerxNcrntal([ieatiug/Conling gupply) Rtgidentint Water Supply(single)
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Physienl Address,Ciq%and Zip
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Canmy Pnttol[dcntifieatinn No.(PfN) --- - —. , `_—'-.
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6,s(are)the wells) crmonent or [I1Temporary ;plip are nr0milfit-d Wall Corttrnaor Date
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7.1,this A repair to nn existing well: rjYrs or (�Nri wdrh I.SA.'4'C X'azc.alna M JA,Yl:AC(l)(-',B?I1D A'erl{;ineln,r>inlr SrnadarA.c mot rhnr t:
iJ7hft iv)rr 7ir..Alto',A•nntt�»varlLstn..tn,climto mminaafid niltrb,• Cr. fifliftrrrnnthophrenprnrtitm10rkm'. Under.
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,r^xnrrmder f71 remarks evom fit(mdn!hnrkaffl)k(trill.
)'L Site diagnm or additional Well details;
R.Imr GmprobefilRT or CAmd-Loop Geothermal Wellx havink the stoic 1'+>u nley iisr.me Nick of this page to provide addillon it well tlito deteik or tuell
Mns,nn:rinn,onl.I M-1 is needed, hulictno TOTAL NUMBIRR rif wells am9trvraion(lenils. You may also atteeh additional pages If nxacsnry,
driiietir•,._i.
9.7rnlnl well depth below land surface: 5U� ____(R,) 1h, �np ran xY ; Slllnnit thi9 saran 3011in 30 days of Cotnnlrlinn of hell
l rotaltipteIreOltli,ralitl.rr1tVf&ffr.rant(<imnph•-d(11Or1'AInddSCatnn•)' cnnatfUciinnto(hcfotlotring;
1(I,9tn6t waterltwcl l►etnn top of sorting: v (R.) Division of Water ReffilwomA information Prnresnien Vail,
Vmwirrla+all+'i ,nac'aving,Ime t 1617 MaR Senke Center,Raleigh.NC 276".9 5 17
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-- —---( ) 2.4h.Tor Infection Wells: In addition to 9cndjng the forttt to Ute aAArald in 24n
iZ Well rontnictloR method: j ubnve,also suhmh one copy of this form within 30 days of completlon of well
(t c.logo:•,rnrnry,r;tt+b �-- corsstruetinn m the following
,dircee tnuh,
Division of Water Resources,Underground Injection Central Program,
fYN2 WATG.R Sf;PM V WF.i,T S 76;t6 Mail Servim.Center,RAtetgh,NC"949-11636
132.Yield Win) � ml ethmi of test: `�..,—� Ile, In addition to mending the farm in
the, address(es) above, also submit one copy of this form within 30 days oil:
I ih�plstnfrrtinn type, Amount: _ r-+nipletion of twit cnnstrucdon to thc'eonnty health depanment of the txmunty
whnrc cnnslmemd.
r•,un,C;w.I North l nm)fnn T)cpnnmeru.of t o.•ircinmrnmm C,tn�llty-Divismn of Water Ramurecs Revig6A �2_201 b