GW1-2022-09745_Well Construction - GW1_20221027

Feb 161905',43p Clearwater Well Drilling 828.622-7241 p.1
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1.WeiLII Contras r In rmatian:
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RRt K 1 L ffiItl'tAGL SIENT MEr 11 AquftcrTcsr DSMfin atcrDrainage I a.
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511.1.atltude and longitude in degrees/minatecfsecondsordecimal degree{ii�vaA field ona tal;4nngiasufliricnfi
fi.IS{rtre]the tydi(A)!Xal►trrDanCnt of j3TCmtlnralx Sign urr ntCerti6rdWetlCBntlaei r O /�77�"'' Dmre
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R.Fnr G 73-Site ftingram or ndAt�fuml wcp datulb:
eolrrohc/ADF or Clnaetl-I a►np Gewhermal WctM having tha sntne 1'wt may use the back of this paga to provide nddiGwlnl ta,eTl attlo JemttA or well
,xnylmMlnn,onla 1 QW-1 l9necded. IitdicatcTOTAi.NVMt3ERnf�.ra drilled_� cdr,9tnlctirm tlrJails. Yet1 maya)sa attach rxldltlonat pa13�if nncessaly
K 2'°tal well depth below land surfHcc: ,h�
1'�r NFINplC xrllrt&all depau fiIl�crent r�cmnlrt_ lorry —tit U f'ar AR W oe: Submit this f m within 30 days of aproplMon of well
1n.Stotte tort tevclf /^v�D' cnn9tiin lion to the folio►4Ltg;
mr below tap of casing.•_ (
!t t�nhv lrtr l tr rrhr,ve cm�»g.uae�. J -tom) Division of Water Resaw&%Iafbrmatton Preeming Vniy
t i-%rcholedintneter, 1617117ai1 Service Center,RC 1109h.NC27499-107
jz WeR cnnnnletlnD method: !�f���� 24 or iaincHlin Wdfs- In addition to r,�tlding ut�I'orM l4 04 sddrM in 241,
alcove,"ho Sobmtt one copy of this form nvitilin 30 days of rompfatio:t or well
(i c,m,g-,mtnry,cable,&44 ti11At,,196.) cnmatrudian m the following:
R WA 1'gil S1;pp7 y WrF 'g ONLY: DIvlSlnn of WaRT Rraaurfxs.Undergrunnd ig(et:flon Conant Program,
13A.Yirld(Rpm) 1636 MARServiceCcnt+er,Palclp,pgCZ709.1636
M4thoo of test: .2de,ilnr for In addili0n to Siding the lean to
13A.I)tsinfeepan type: f6a addrrss(cs) nhatle, a1sD submit one ra of lhfs fetal within 30 d
Amami. Completion of%veil constsucdon to the comity health deRanmem of the > of
whmG ettltstmeted, coutnty
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AhetL(Snminm lk�,nrrmem orid9.•1.dnmcatal Q,mllty-niviwnn De Wfi rt•1Losaraese
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