GW1-2022-03348_Well Construction - GW1_20220314

1=eb .5 119 05;43p Clearwater Well Drilling 828�22 7241 P 1 . .
WELL (GW-f_) Fnr Intemnt Uaa On
11["-"ttrrtc nr formarion:
-----'--
Flttrk •--
Wett C olinaor Name R.
K Wen Cnntragnr C"fication Man6 S.piil(RR CAtIING m rrefb��� a Mme UL
V� , h�l j/'1�1 tmnM ivs nr to ens
.t D
Cm-np+my Namc —
f 6.tNNER G49)111C OR Ttl N eherrwtl t 4trttg,),^
2-Weil Cnmurttel)en Permit rl: ys To ou ssrfcta+trfs stAtEweL
i.7.rr I'!(appifmhle irr)1 rnitrtnrcilnn pernNGe(G'.1JIC.CmrMy,Stole,Y.trtmrcc,err.) _
3,lYrlt tine(check We ase)!
n•. Q iw.
Water Supplv'Wefl: �I .6c
tmoes to nrA>++ssrr of t;$s 7HRtA1.
ilaricultural tyttmicipal/puhlic 0 R. tt. Ur•'
0cothcrnlal((•ieating(Coniing Supply) Residential Water Supply(Angle) ft
ft. 1n
i Gtduxfrial/Commerciat 13ResidentinlWsterSupply(shared) 4GROUT _
[rri colon er MA ut. P C¢alVFr n14AT70UN1'
A. [a
Nan�1'nterluppf7Vl'el[: _
A4onitoring �Rtx revery U, fe
Rieetion Well:
tt. R
Aquifer itt:charj;c QGroundwnter Remed'eatinn
�19.SANif/GRAVA4PACK
rAquiferStgrilgo MA ikeenvery 133aliuity Blume mtoyt ru 1ttA L tetacenlsnz'?rrt rttaa
AquirirTcst UStarmwaterDrainage fL a.
Vxperlmeniai Teclutol(w [3Sutnidence,Control n• �•
Geothermal(Closet!Lonp) 13Traccr 20.1Nt1Y.L LOG reitseeLadditlawl Itrrl =R
RRa7rt TO H 4t skaete.t
CicathennRl ft{catin aorta R—en7tml Qtiter(oX loin tinder 07.1 RcmRrt.$) it. Z R _
4.tlatc Vi'NI(s)Cntopleted: l�G ell i>)fi ft. ? (c r L
CJu Well)nratl n: e s 1 t t`�i[ �"") .. ••
IWAA _
I:tci it1:r(onto ltamc FuOity 1ptt(ifapplienhtr.) h• R• ( �-
6- 1
Pr�j[ACArcjt:, -MAR-
T -
�{ /1%C' ?I.RiMARKIS
t'.,nary Y1 7 hated rdentificadon Na.(PIN) - _ —
5b.Uttitude nod tonfi)tude in deltroulraimrteslseeands ordreimnI degrees:
(ir twit field,one iatgang is sui£tetetn) t2. .e ration:
6.Nare)the WCii(. crinnnent or ©fi'rmponwy :i cofCrniputatdiCrmtmetor prae
T_ 1,,( J.v st�mir+h tlilr;firm.J hrtwhv rvatfl+that Idr axU(xj Mai rlT -)umnmrftul In accnrAmrcr
?.1.;this A repair to an existing well: Oves or No rrtrlr J fA 4 D2f.t11011 nr tSA$Cal 01C'.IiXtO Wr/1 t:.rrr/rrrenan Sinrrdarrf<mr�l rhm a
9'rl.1e ix o rcpoir,,f it inrrkwim terrll e1mvirnatfut irtrormatinn eopiY nforle rrr nrd har?'n"pror"W ift ft Wen nmxr.
-,wir undor B1l remnrk.v uejjQn nroath.harkofr)kform.
23_Site t1bgram or Addlikttml wdl detatts:
R.F4r C.&W CIAPTor[heaed.lsrop Geothortanl Wells having the ssme 14xt may use the back of this page to provide additional well site detnite ar weil
L'Onsinrrtinn.a ly i GW-1 is nccdecl. litdisettc TOTAL.IVLIMBEit nfurps afnstractioo details. You may also attach additional pna ifncccssary.
drilled:_.___.. o
.. ._ - .... --
�o �:f:?�ICETAY.IR,�tttut:'tsa»s
99.TOW'well depilt hcltro'land surface:__ Aft.) 24% OLA W h.- Submit this form witlfin 30 dRys of completion of well
1"nrrxnlnpleW/1CuuM;dep1hx;f u"nr(exan{nh++(nl?r!P'omt•�ii`1t7Ay cons ction to the follmring.
tn,S(R4e water levt7l below top of easing: ([t-) Atvirinn of Water Resources,Infmrmatign Processing Unit,
tf-kr imw)IT r/horo cm,41R.trAC 1
G 1617 iH>tii Service Center,Italt!igh,Nt.27 -t617
li.t)terchotcdlnmetet: 0 (in//,j�� ���� 24k f lAiReti We111: It)addition tosending the form to file addrft it)241
12 Well rnnserncllnn method- . 1.C.t.�IJ��YL,{ alcove,also submit one copy of this form within 30 days of completion of well
(i "'r ------ et►nsiructian to the follaivin
t;e'. nsy.r.�trk directpttslyetc.)
FOR WATE1t Sl:pM V WI?IZS ONLY: Division of Water Rtmrcl3,Underground Injerwo CORIM)Provilm.
( 1636 Mail Service Cenm;Ratelh.NYC 2709.1636
138.Virld(gpm) I V Methad of testiiaai
2 t�Fac Wptar SHE&&iaiccfton Welts- in addition to sunding ltte form fn
the addres(es) abov , also submit olte!copy of tills f0 m within 30 days oC
13h.Disinfection type: �� ,Amount: completion of well cansuuaion to the errant}health department of the cntmty
athcrc cttnstmcaed.
barn+Gw-I Norlfi Carniinaf?r�nnmcat nfiin ircintnu:tal Quality-nivisrnnn>'Wcuet Roymtrcac Revised 4 22-201 b
I

ATPy,r Rezql-l-oeq
Owmr ,- fry kf /e f �t ir'NeI�:_
z h��sy cexti�r t��e�bave�f�netxce�w�A vu �Xraut�d iin ara�ne��noo�nd w�tt�
Mdtm-
�11+Caunt�r Wilt races
WellTAlue�r• SOW,
C m souction:
TOW ., . 'gyp,,
c
Casing D"!o2a S pm: J-D -
DrWe