GW1-2021-00349_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD F
This form can be used for siacte or multiple wells _
1.Well Contractor
,.Information-y
S itJLJ f L1LY (+��tr jj�� 1 FROM
WATER ZONES
FROM TO I DESCRIPTION �
Well Contractor Name
i
- - ft. ft.
N('Well Contractor Certification,\umber I IS.OUTER CASING for multi-cased wc#fs'OR LINER ifa able
} /� FROM T DIAMETER I TFIICY-MESS MATERIAL
! rt I VIVA 0 ft. fr. 114
its $ all C
Compan)Namee �� -16.INNER CASING OR TVZV thertaal ei -
1/� ]/ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: JO � ft. ft. in.
1
f r.+t all a/r/SNwhlr xcll cnrzrtrurtion prmtits&L.(•ommy,$rate 1'tarraucr.ercj ft. ft.
in.
3.Well tine(chick well use): 17.SCREEN
1i'gter Supply Well: FROM TO I DIAMETER SLOTSIZE CKN THIESS MATERIAL
QAgricultural OMunictpal/Public ft. ft. in.
--Geothermal(Heating/Cooling Supply) V<esidenlml Water Supply(single) ft. ft, in.
QindustrialiCommerc:ial ❑Residential Water Supply(shared) FROMROB TO M I ENtP ACEME\T METHOD&.A%tOt'1T
Cirri tiun ft. � -ft.
Non-Wtittr Supply Well:
i ft,
D.Monitcring ❑ r•Recove tt.
Injection"Vell: ft. fir.
I
QAquiferRecharge --GroundwaterRemediation 19.SANDIGRAVEL PACK ifa licable
QAyuifer Storage and Recovery OSahnity Barrier FROM fr. ft,
TO MATERIAL i EMPIActmEITmirriiOD
QAgtiitar'I'est 0StonnWater drainage
ft. ft.
GEaperimental Technology QSubsidence Control 20.DRILLING LOG attacb additional sheets if necessary
:.:Geothermai(Closed Loop) OTracer €anAf TO D' CRSP'l't0\ tatar,hardaeas.sod/rotkn t.-nnsiu,erc.
CGcotlicrtnal(Hearin=Cooling Return) C:Other(explain under r121 Remarks)
fr. fr.
4.Date Well(s)Completed: fc ft
S.NN'clt l.oca�ion: ft. ft.
_ ft. fr.
F tliil.t7t�narName Facility IDTiifappiicablej
t� ,�� ft. ft.
M,Q L7 U _t[y ooA ft. ft.
Pil) i al Address,Cite,and Zip 21.REMA
_ 15�-33
t:'ouun Parcel IderuiticationNo(PIN)
Sb.Latitude and Longitude in degrees/minutts/seconds or discimal degrees: 22.Certification:
pf well field,unc lot long is sulKcient}� Signature ofCeniGed Wcll Contractor4&"ja'
c
6.Is{are?the e'ett(s): �iPcrmanent or QTemporary
Hy siga»g tlns,fnrin.l hrrrh}'certify rltut rhd ire/l(j)sloe(wrn)t•a+avyrattrr(ur utcurdcurtr
with 13A;Yt'At'11?r•.1J101)or 15A NCAC 02C 9.761)it•ril('oortrravniu tirnurlr+rrtt and Thar a
7.Is this a repair to an existing well: --+Yes or �o cu1.(t'u1 thcs rrronrhas hrru prnvitrrd to rhaurll ux•nrr.
1/dim ra to refwer,/"ill out kurmu well Lrgwrot•nou rn/orrnalrrnr and arplain'the..hvlor�of I e
rt/wx wider.,21 ivmorkr wcnon or on the hark of ihrc fora. 23.Site diagram or additional well details:
iu may use the back of this page to provide additional well site details to well"
8,lumber of welis constructed: >� t L construction details You may also attach additional pages if neccssar�:
._..,.;� d
l•i+r uinlopie in;vomm�or nun•xt>Iirr.rnppA'ii rl(s gti1.1':rrlh.lhr anma cvuteltlt c art.V'au c'ao
,uharlanrh,rnr 24.Submittal Instructions:
9.Total well depth below land surface: 3o j r` i`' '•- ''`'``{fii}4 24a. For It Wells- Submit this form within 30 days of completion of%%ell
1•i r undill+le a el/vhNi all depth-.rl r(rll+reul texa eplr•3 2m),and 2rti 101r) �'' construction to the following.
r-
10.Static water level below top of casing: "' (ft-) Division of Water Quality,Information Processing Unit,
rl,iurrr1"vel"ohore oir.•ir,l. - " 1617 Mail Service Center,Raleigh,NC 27699-1617
//�� i Ig
11.Borehole diameter:�IIJ - {in.) 24b. For Iniection Wells: In addition to sending the town to the address in 24a
above, also submit a copy of this form within 30 days of conipictioi. of tvcil
12.'Well construction method; 21A fa k�_ construction to the following.
(it auger.rotary.cable.dims push,ore.)
Division of Rater Qualify,Underground Injection Control Program,
13.FOR WATER S1'PPI-Y WELLS ONLY: 1636 MRit Service Center,Raleigh,NC 27699-1636
4 Method of test: �" i 24c.Fit r Water Suonly&Cate �othermal Wells: In addition to sending the form to
Yield --L the address(as) above, also submit one copy of this firm %vahin 30 days of
13b.Disinfection type: c0orfo Amount:`••3& C) completion of well construction to the county health deparimem of the county
where constructed.
form UW-I North Catalina Department of Eniirunment and-Natural Resocwea-Dit'tsion of Water Quality Ret iscd Jan 2013