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HomeMy WebLinkAboutGW1-2022-09806_Well Construction - GW1_20221027 Feo 16 19 05;43p Clearwater Weli Drilling 82M22,7241 '' p.3 EJGL ON ' T7CTxON RECORD ME 11 Fnr lntcmal UseOnly: ' 1. lit('.nnlrat;t,nr nfoelnatlo : �� ' 14,WAWMZGNRS iv(+li�fan�Uralgtx 1Vrne turow n euCwnteagvtr�fei:atfonN,m,Met' I n 1 � { t R Alli 151t a tYG ter OIC a iaf �J y 1 ,RUAt I TO PIA-if- 7LI IffiS MA1'EItUL CaatlwtayNnma IL C, 2.1'Pell Conairnetion Permit t3:_�(�OS� ' Q n ^16.t1ViVBR C QII R6ertea! 110 all H 4 DIAtKCi�R NA c apJtlienbGt wa11 tnxrrtrtctlart pastas n a r/!C,Canary,Stag Vaniva;crs—j"""^"` t6 tt fn, �.lYt9111.ge(Cht:Cli{Ydl ll>ZC). - n•. R hw �varcl-Supp�y 1t+c)h �17. AgriculturalMuttielpal/Puhiic VAOM ITO I 0PAW&Mit ses A uL p R. is C7cahcrmal(1•Teaiianconlingsupply) g-Residential loidendfilWatarSapph,(singloy hldusrrial/Commercial Water Stipple(shared) a if'f irli noon Novo lYntcr5MUM! I uppfyWcil: Tlrr�� A L rt'r' ns� tour Mouitming R- C74 V fir, 00 lnjeation Wall: Recovery U. fa. AquiferRecitarge E343roundwater(tamediation 1 n- R Aquifer storage mod R¢cnverp iDSalinity Rasher ,f9.SANDIC 1 L PA AquiterTe•st - M i t; C 8re1 t rnlon �SrnnnwAtcrDlninnge: rt. n. Experimental TcrJtnoltl/,y DSubsidenee Canirol B, n, (10 Aemtnl(Closed Loop) DTCUcr X DRILL LtyC ch (� ticolbmnal satin oOlin RcIItml Qiher(explaiaander$21 Rcmarks )'mil?_I Td Y sk t,Ilatak'ell(s)Cam eted well IDti -75 R. 5u.Wctl I:ncatinn;���.�,���l.Vl l 't I(/(Ce re. f,.�1 � y► - -`�'t ell Ay t e.teVit4t'f)mictt•Fama . Facility(E7ilGftq,plicabrey 0. R nve:c, Dr. RA ekJ y�z 4, � ..,���Ar nddres5,chl.,awa pep County Itntcel fdcotiiicatinnNa(PM— [ L Alt•t,gHtada and longitude in deg,'OWMI11,llteShmeandsordccimal d It&�u^ra�i.�i3t1 1�r� (i'wc E I anS la eg etc, Unit a tRangia9uiiicic+niy ( ,� „� --�b__._�l � ��� ��f �l,�J•O� '" ertFllcntinn; 6.ls(urtyfhcwclt(s) PcrmAnent or ©Tampnrnry Ssrinaturr.of CcrtifirtttNell Cantmeter axe +.it Q,Fz a rc atria atl existing wcJi: �Xas or �No f,;v.etynm�well;oral,�hrmfiv t�r1 mar Mc i�y„j �p will,)3.t:4C'AV 02C.47109 ar MA N"C Aar.'AI2AD rVrJ f i r Ern °anti ? Cfddsi�•nrrprir„/AlutudmnwmtwJl.�nacrmurnnlr{fp+�ttal7mtondrtrplpinMon rxtmrnnjrfir CnptrntUtferccnnlpaAberglpigt7duftnlhewellmvttrr, rr�rtirundcr S2r rrrnarl,s,rcettannrnntlnhackgrlG/,Jrrnw, R,Fnr G 23-Site diagram or nddidono WalldeAgtrs:eoprnheMPT or Closed-Lonp Geathermill WelLj having the.same Vow may use the back of this page to provide addilfonid wail anla daWIS or watl uonsttmxlnn,on' 1 CrW-1 N 11ceded• I'ndicata TQ"fni.NLIMBER nf.,.'c11s dril{�I-___.... cot>9fgtetina tlHails. Ybu tnayalstr niWah AddrtianAi pages ifaocrssary, `J'.To'-"wc11 depth lwlow land urecc: �U� r��JQMITi AI,INR1 R 1 aNS rotattrttlplcWp!/CiltralJdrpllu rJdjjcrrar fcamaple.3020(rmrd2t_a11a09 �'�`L fi Ali WM' Sultufit 06.4 font:-Min 90 daya of cnmplclion of tivtll eongMw4f on in the lhllo{sing; M.statla wnteriyq,ei below top ofcnsfnge,,.r,�_ 1jMnr,rlarcliritFtnttcaring,irae ¢ -- --M.) Division ofVYarerRemraes,InfhrmatlonPraeasionVnit, 11_Bonmholedltimetem-19 1 U 161711?t+9ServicaCet:Mr,Itateigh,NC�7599-16tT �n•1 Aittr._ nr taicrrinn Wci tit ado?Wn to rendln tZ Wei;conttrnetlm{method: abiwN also submit any of this fotm tvilhin 3p ays lia thtt iati n in well U e•cane-,mh --- .--�. citw�ction to the{otinwin dt orz of weft 13',r,71fIC,tUTGSt pllsit,L'IC,) �'��11W_AITT_M_1,1 t;PPI y VV,LLS DNI,V: IMMIon ofWater Rtsmirm,Underg►olind in Eflan Control n f 1r,36 WallscrvictCanwt•IRAtel ,NC2709616J6 dram. II�R.Yield(r3Aln) Nethal of tAgC tL� ZIP ltnr WutOr Sonp)v&#piPrHnn w n to uddilion in smditlg iht thmi to 13b.plslnfcenan type; Amount, the ndAress(cs) nbtltat, also submit one copy of this form within 30 days of completion of evcif eonstruetion to the corm whore ennsimctnd. lY health tlepanmeat of thG county I'ttnp Gob'-t iVonLiramllmtDepnnment aft3t�-ir,l,rmcnril Qraalty-Alvistnnof Water ltosaatcec RP.vNed2222e16 Date: Well Case: Well#: c D00-7 4 Name: ynen G ep CU Address:60-3 FOAI ea-my IDr. Pump has been installed well head ready for Inspection. Sign: - C{reaarw� lnlP,& Drri, bA-g i