GW1-2022-01117_Well Construction - GW1_20220107

Feb 1519 05A•3p Clearwater Well Drilling 828-622-724 1 P
WExrL Cp�TSTRUCTION 12FC�RD{GW�a.� For Inlcmnl Use Only:
t,Well Con tractor Information:
K Nei) i4 W TE AMES ----
At Tn AE9 RII'P1bN
Well C:ontraacclot Milne fit.
fit. It.
vCWell Ointractor Certification Nrnnber f IS QUTERCA3ING tarmotNtasedwrolis
&Tff ORLiYF.R !fa e
p/ �(� �D { _PRi1rA M1 A1 Ft TIIIMEBS MATERIAL
C�� 1 t\'i
CampnnyNamc C1 l ER CABIN OR'f1iRiNC thorwattctoeed-tau
2.1 Well Construction Permit M. C l�f ` a 1 K To DIAmLMM rAIM"NEss MATVAIAL
i,i.c1 all nlryrlicnble well cnnrlrNclinli parrnat(i.e.INC.Conroy,Sra7r,Y.rrlance,crr._) _
ft•. h. in.
3.W01 Ilse(check well tise):
AI7.SCItB N
WatcrSapplyllteN: TO AAM87rR SLOt. TnlCKNg4a 1tA ut.
AgriculttiralMtmic)pal/puhl'tc (? (t, ft. in
Geothan I(Eleating/Cooling supply) PResidential Water Suppilr(single) h, ft
tnduslriallCommercial Residential Water Supply(shared) g GROUT
Irtl^atlDn NROIa'1 TO MATERL#L. LANPL7ICE £Yratn'flt D&AMOUNT
Non
rt„ fie. �� 1\Ymftr Supply Neil:
MonitotingIQRconvery t�. fr-
Iniccti�n Wdr:
Aquifer Recharge E3Groundwator Remediation
f9,SAMl/G11A.YELPACK fa Ic
.AquiferStoragc and Pccovery E33alinity13arricr PRoltl[ TO MA I L B{1trCACEMBtVTMCFItOn
Agt»ferTcsi [IStorinwaterDrainage r n-
Lxperimental Technology [)Subsidence Control fit n^
Geothermal(Closed Lrrap) 13Traccr _xb.DRILLiNG LOG atlaeh tiddidanoldiaiftifumse
FROIvr DEli itiFt'ION cube. gphaakt ralna etc f
80colliennal(Reatin oolin Retum) Uther(ex lain under_i121 Rcmark-S) '� tt. \TO
4,Date Well(s)Cotapleted: �-5-Z_Well ID3l � `� R. 1 it
lSZ[N u_x- 7o ' tt. Eft.
2 -
5a�w,rt1 i.nraCR f! d inc
- �har ilih:rr mnnerrHaame//]] Facility IDtl(ifitlplicAVr..) n
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Phys' ,f rccs, .ty,end Vp rf JAN 1.
kV-Do
parcel Identification No.(PiNI
5b-LRti tittle and longitude in degrees/minutes/seconds or decimal degrees,
(ir sw11 fie)d,one latflang is sufiiefcnt) , 1 1 �2. Gcation:
®� ��t loll N UO) CD 3� -�0• Z1
6.1s(are)the well(S)permanent or ©ITcmporary Si mar nfCmifiedv✓et cmvuCO Date
12v,rl}mlag Nux.,`nrm,7hervrhrrxrrlfj+Thal the arll(,) was(irer')crmrurrcred hr aumrdmree,
?•isthisArepairtoan existing well- Oyes or 10
No :�:111MA.tiC,tCOW.monorIM AMC n2C.l1204 Well Conswirruar9andoed.rrradAma
fr'rhlr;x a repair.fill ra known trill eansrrucraarr aTfhrmalion andcxplam Ow rewire nfjhu Lnlflr r+flhEc reamIAao been PMilideAlh Me wall rtMler.
rr�plr rnldcr A2 l rrmnrks scrr0ut sane the hack njlhis'.farnt.
1.3.Site diagram or additional well deMits:
R.Por GeoproheMPT or Closed-Loop Geothermal Wells having the same )'oil may use..(lie back of this page to provide additional well site details or well
conslnrction,only I GW-1 is needed. fridicato TOTAL NUMBER of-,vrlls congtntelinn details. Yott may also attach additional pages if riccemaly.
drMdd!_-^_._- $l l A[,jtj§jR111 YOiVS
9.T0121 well depth below land surfacc: 9 J __(R.► q,Ly )For Afl WNk: Suhmit this fotrn 1vi(hin 3(l days of completion of well
7 rr nrrdrrplr x•Nl.rlivalideplltr jdrj/er err t'rrnmplc-J3(nit/p'(r�'oad a[ZiOQ) conslnietilm to the follMing;
10.8tPtlle wathr level below top of easing:_ 1(1 V (fit.) Division of Water Resourees,Information Processing Unit,
!j'arjlerh-mr!ist hunecaving.Inc
"•.. 1617 A1siA Service Center,Ratetgh.MC274"46117
it_Borehole diameter: lX l(in.j z&h,Fnr Iwiertion Yells: Lt addition to sending the form to the adlImm in 24a
12 Well construction method: -1 alrove,also submit one copy of this'form within M days of comple ort of well
-----------dirt,;t pttait, ernnstruction to the following:
(i c.anger,reMq.c,•illc, sKe,)
ErORWATER7,8tCPP1-VWF.I.LS f3Nt Y: Division of Water Braources,Undelgrealid Injection Control Program,
f, t636 Mail service Center,Raleigh,14C Z7699-1636
y Method of test: 2 tc. r yVatcr Sppety&Fn)ectiori Wells: In addition tosundmg the form mthe oddress(cs) above, also submit one copy of this forth within 30 days of
_,_,��w Amount, completion of well construction to the county health department of the county
where constrnctt5d,
1'nrm Ow.I NorlbQmlinnDeportmentoftin.irnnmcntalQuality-DivisionofWaterRosonram { Rwfoe12222016