GW1-2022-09838_Well Construction - GW1_20221028

828-622 4241 PA
Feb 1619 05:43p Clearwater Well Drilling _� •�°
WELL CONSTRUCTION RCURD{GW-1) For internni Use Only:
1, clt finntr etnr 1nf�tgna�on:
_ 1,YYY))1lll 14 W' A ZONES DasCIRUI ct
trtto„ To
SVef(Ca"tratlac Name
VC well Cn/nr�raam CadficMiian Number 13.OUT Ely C NG Farm®ld•tssedaelK ORY.L?II�R tf® !ICBM
�� i l /t W�J�•1 �^ IIROAt O � DiA1KFTLR 'rlilClrNEBS MATERIAL ,
/l l JV1 It t ( It fV 11�
CnmpnnyNnme n 16.MNERCA91NGORttISING 4190011
1SROM TO D--ML Pal. THICtIIY>v9S MAtgntA[
2.Well Coa%trneiion 'ermit M f!. In.
i,lst aft0ppiirohle mall Mrittnrcr/nN pturtNls(I.i 111L•Cnnaty 1m`f�V anrc cr)
�• in.
X.IYddl Ilia(check lvdl use): —
17 S EN D�r� suorso.>i •rtttcrctvess 'ranul.
1 e]-SuppL,vWell: ]FROM TO
Agricultural prLtpicip$11Puhlic o D• n- in.
t,eotbermill(1leatingicooling Supply) esidential Water Supply(single) IL fi. In
lnduslitaVCommi=id 13Residential Water'upply(shared) I& OUT
� Tp MA'CEaGI. HINPI.ACHRtE7rT}/r'7'HOD7k AptOIINT
rrrigntion
Nnn%VntcrSupplvWrill:
Monitoring Recovely a. fw
tn.jectian ell: M tt
AquiferRedtat�c QGronndwutCrllcmrdialidm 19•SatV1])GRAYSLPkCK iEe tkable
aqui fur Storage and Reeoven, f3SnlinityBarrier FROM t1. TO n}AT�tIAI; EIHPLACEntr.tvTlStCrltOn
r1,
Aquitcr Test D3mnnwater Drainage --
L,xperimentsl TeaImolov C)subsidenee control
Cseothermal(Closed Loop) [3Tracrx 20.DRILLIN juldildenal li �{nctt+xerl)-
FROM TO PE5 rain ikpeta
GeoMermal tlrcatin oolinR Raul—) otber(explain under#21 Rcmar6-s)
c n� Y
d,DatWell(s)Completed: Well IDY R• t .� SAS`_ -�—
Sit.Well caNnnn! p ( �•%
t) e- e �X. +
l:tclig:'Onncr llatnc ., I fL
Facility IDM(ifaPPlicahlr.) '
Phvsienl Address City,and Zip
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' —,^ �, PMD`I 1 21.REMA RKS
1(
County Parcel Identification No,fPPit
51)-Latitude and lonAitade In degrmslmimlteslseeandsordccimal degret-v.
(iiweltrreld,onelat9nngissufiicicnt) „2.Ce cation:
W
�,,,�� Sit ureofCWlGedWellCanhaetor Dale
6L Is(ate)the well(sJ#i Pcrmlineal or ©ITempnrary
jj/� �� Iry 1(mi0g tfNxi+,rnr,l ltrrv�ryra+tl�j+fha fhe nvdllaj nvrr h+m J cngraurfid!n occotrVmcc
7.is this a rcp$lr to$n Cl79Upg Wt 0: l'CS oc lYo ua r 1 t1 tiC'.rC 02C..,7100 0r 15A,YCAC 02C',(0200 Welt COrurrrecrl0lr Srandarde mu!rhm�r
1•,rdlr isn rclx�ir,�►1 m+tl0tnum null.o0unusmn in/brmali00 01 pin the rrnrrrrc nflhu
c py nfllrft rCCMV1 bar berm protdr 4IP the we awrder.
r.epnir under 12l rrmarlGc sttpnrr 0rrmtla hock pflltrx fnm+. 13-Site tliagrarnrn or additional Well derails:
R.Car Gcoprohe/11PT or Closed-l.onp Geothermal Walla having the same you may use the back of this page to Provide additional well site demih or we:11
mnstntctian,only 1 GW I is needed. rndicma'WrAL NUMBER or-allc CI)ri4tnrrtion details. You may Also altach additional PRO if treeessary
drillccl: _ -- Clit"'� _��__tT1 AT_ttti$fR>~ICT(ONS
9.Tatar welt depth lwlnw land surface:_ 2 —(ILI -%L.,rtnr An Weltu: Submit fibs:Form,within 30 days of complMon of well
lirruruhiplrwetsli.vand..prize•jdffcrrnr(examolc-3�1//4��0eo0di0[Z1001 congintrAitmtnthe fQIM111g:
lee Scotia water level below top of casing:—I/ (ft.) Division orwater Resources;Information Pmeessing Unit:
lf'waherlrrelLvabomrraslnS.Tree•.-..1 'W
�C 1617IServiceCenter,Rsteigh.NC`174!10-1617
fi_Il orehoted U N ininmr: Ly (In.) ZtD.For laierr to addition to Se:Ong 0M form to die nddrea in 248
^� n above,also submit one copy of this form tvitMn 30 days of completion of well
11Zweli.constnictlonMethod: }e l '` cnnstruetiattm the foilDwin�
U c.anger,mrary-cable,dirmt push,cte.l
Division of Water Reaaureet,Underground injection COMM]Psagram,
POR WATER SUPPLY WELLS ONLY: � (n 1636 Mail Service Ceatw,Raletp,NC 27699-1636
13$.Yield(gpel) Method of test: 5U Iv 2+te,rnr y►'ater SCrpQlr&iaiccflea-W In addition to swrdmg the Form to
tUe addresses) $bovq also submit one copy of this form within 30 days of
13h.Ulsinfeetian type- Amount: Completion of wdl Construction to the county health department of the county
whare constructed.
i
i
lrorni Gw-I North CA-aljrmDLTnnrnent of tin.5rtinment1l Quallty-Division of Wwar Rosoareea Reviaeri2 22 2a16
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