GW1-2022-07069_Well Construction - GW1_20220729

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Feb 1619 05:43p Clearwater Well Drilling
WELL CONS I'RUCTIOIY FMCCIR _GW_JA 1'nr internal Use Only;
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1.TICnntra]Iq formation'
WATE l)NES pESCRIMON
ate
Nr,:Well Cnntmdor Certlfipation NlnnFcr `� ' l l l lS.OiffF.R CASING cormat t ORtttcxx�9 a MATrdt1AL
``� �A goat m
It., ft- in.
C,ompaay Namr. 16.INNER CASING O[t Tti ING of�MErI3t iormid c�lmed 180 MATERIAL
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2.1Well Conlltructinn Permit#:
�/�r l J � ROM TO
rA k in.
i.irt allapplienhh!well rnminter/an permit.%(Le,tAG,C.pnnty,Sraic,Variance,ef:.) in
3.1WeN 115c('check well Ilse): "17.SCII&EN
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ersupplyNvell: PROM TO nfAMZTMriculturalMunicipalMubtic U tr, ft_othermal(Heating/Coctling Supply) [3Residential Water Supply(Singtc) ft.
dustrial/Commercial Residential Water Supply(shared) 1&oRQUYMATERI,uL EMpLAYr?tETROn&AMOUNT
tptlon
Von-11'ar cr.upply V4'rll: R"
Recovery
Monitoring -
lnjpetion Well: ft. R
Aquifer•Recbat);c �«1Groundwalcr Remcdialian gtVTrtACBMBNTMCT1700
C..1 -19,ySANi)IGIiAVELPACK Ito cn e
Aquifer Storage and Recovery C)Salinity Barrier PROM � r � . MATIlI 1AL
Aquifer Tcst [3Sinrinwater Drainage
Lxperimental Tcehnology []Subsidence Control
Geothermal(Closed Loop) 20.DRILLING LtJC sitaeh taddl onaltthaets ifnseremmm"l
PROM TO Oft WiT10N takrr. 00tthnek+ rate eke
�fTCaccr hard Or.rlas,
Gcothern,nl(Hcatin*CoolingRUM%)) [30ther(explainunderfi21 Remarks) it_ fl,
tt, _
.1.02te Well Cnm eted:�� �-- Well inn X.rr. BE �
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Sa.Well I,orar On: `cJ�l,l`� \i/�� {� ft. -------------
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Pa�litv!(ln+eT)famc Facility IDid(ifopplicAblr.) _
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Physimil Addrecy,City,And Zipav
ARKS
Connry Parcel ldcntification No.iPIM
5h.Lntitudc and lnnfiitude in degrees/minatos/seconds or dccimnl degrees: —•"'
(ii%ve}!field,one laMnng iA sufliricntj o �
r ,<'TtificANnn:
�,,((' c nrCrxtirLd WellCantrnctor T Data&Js(arc)the well(s)0'rermanent or DTrmporary
TTii�� I'rtl.vr}minr tJ+lc,lirrm,1 Gerehv verrljy Urnr the urir{.J ar+r fwereJ crrRsritrcA?r1 Nr acmrrrn!rcr
7.its{hie it rcpalr to an existing well: InYcs or No x•Yh 13A N!:'AC a2.C.0100 nr 15A rY(,AC 0C.'.020D Well(:aurlrnrruur Stnnrlarrir and Thor a
tali),oftltts rreord boa hmn provided m rile wall owner.
!,+'thus•is n repair•fill ontknaNm uYll,.'Msrnrctrnn AlfMmnliOn mx rxpinin the onuure nfnc� �J,y "1�^^F> zb
repairraidcri.2rrcmnrks,rxrinnnrnarin:hnrknjrhi�farm. t U _1 � r
23-Site dfAp,Mln Or additional KCII details:K b_ u„_,4 r _;�,
S.liar GeoprohellfPT or Closed-Loop Geothermni Wells having the same you may use dtc back.of this pogo to provide additional well situ details or wall
Lonstntctinn,only i CrW-1 is needed. l'adicniO20TAL NUMBER of wells construction details. You may also attach addition7J1 p 'C12*f 113T7 2
�l�rT'irnr I1ti aritlui:_..__ _ __ t,v��l S 35D -siTRut 7TONs J tk_: !r L LI L
9.Totat well depth;)Clow land surfRce: r�^0:; �,�rt' } U q_(R 1 4Aa. Ior Ali Wellc: Submit this form �vitltin�0 +5 7feun art well
For n,iilaple Inelrr liSr ail daprhv ifd ffj mar(examnlc-9n200'and<@1001 construction to the f0llotTing:
I0.Static water level below top of casing:. (ft.) Division of Water Reauvrecs,Information Processing Unit,
9,410ter hme!is nbnra roving,rrac " 1617 Mitil Service Center,Raleigh,NC 27499-1617
i.iktrcholc+iimm�tcr: (in.) 2•Ih.For Yrricctiott}Netts In additinn to sending the form to the nddress in 24a
at)ove,also submit one copy of this form within 30 days of compictirnt of well
)2.WeV construction method: cansttnutiott to the following-
6 c.nuge.,rotary.Mble,dims push,sKe,)
Division Of WAtcr Resource%.Undergromid Injection Control Program,
MR WATER SUPPI-V WF,I.L,q ONLY: 1636 Mail Service Center,Raleigh,NC 7.7699-1636
13a.Yield(„pm) ifethad of test! T- T Me. For Watcr Snn v&IMEN11011'Wells: In addition to sanding the form in
Me address(cs) above; also submit one copy of this form within 30 days of
13b.Disinfection type: Amnrmt: completion of%veil construction to the county health department of the count),
where constructed.
1+annGW-1 Qnafity-DivistortofWaterRrsoureec 11CUN d2222.016