GW1-2021-03095_Well Construction - GW1_20210625

[`(jr Internal f lm Only:
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NV ii'cll C�ntmrrnt t'cnitientimn Number I i L61lTEtt C StNl/ fni tirultl-ea+H!wetly R tANf.R i/a inhk
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mram Namc
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2.N'NI conslrucrinn Permit N: I FROM f To 11 AMrl'rR I TIIICKNFCS I MATFRIAt.
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3.Well tlac(check welt use): tr. tr. in:
ii'ater.Supply ti'ell: 1t.SCREEN.x;<
A nruThmnl S FROM1t TO DIAMCrER SLOTSI7.E 7111CK`t�Sc M1IATERIAL 13Alunicipal/litbhc M ft. in
G*cott+ertnal(itcating.+Ctroling Supply) Residential Water Supply(single) ,
lndttctsiallCommcraiol [3Rcsidcntint Water Supply(shared} l � /3 R ✓Z im. G 1CJ 5r"�(i j�v 1r
`1tl:.GROCtT-'=•_r ,;._ _;• >.. - s�. � =:r .x .: ._ �,.
Irri .tion FROM I TO MATERIAL I EMPLACENLvr ME 1101)A ANOVVT
\ern-'sVater Supply AVell: a n-
A1onilorinF Recovery
Injection it'ell: t r50
Aquifer Rccltargc QGraundwatcr Remcdiatinn
19.SANDMRAVEL PACK I/a licable
Aquifer Stomgc and Recovery OSolinity Barrier FROM TO I MATERIAL EMrt At rNfYt.NrTltlfn+ "r
aAquifer Test OStorTnwlter Drainage if(i h 7 3 n" -l+
DExTiCrimental Technology C)Subsidcnce Control rt. n. IV '
t3GctrthcrIal(Closed Loop) [)Tracer 20:DRILLING LOG MIN IF addidnnal AMM i/neeessa
FROM To MCRIMON rehwr hared«uWreA -?++.err.
Gcttthtalutal(11c�tin rrolin Return Other c lain under k21 Remarks) It, n.
Q.Date Well(s)Completed: '.l _ Well im rt IL
Sa.Well Locatinn:
fa ft.
Otun5"-rL L�,Clre, It. a.
Faeitrh•1Z1v ncr Name racility[ON(ifapptieable) M n-
pri3c, f i%,V- (24 -Atienl Nr littler fL ft. UN 2 5 2
021
Physical Addrevs,City.and Zip
RrW6arr G -2f:RET►tARKSK"'" *'<v,� .- fl v
County Parcel identification No.(PIN)
Sb.l.slitude and longitude in degrees/minults/seconds or decimal degrees:
(if well Gcid.rnic In-Anna is sufficient) 22.CtrtiGtadon: Jl/(Wt1 q<�-S"f?
6.hi(are)the well(a)OPertnsneat or ❑Temporary Signature of Certified Well Contractor Date
By t{gning thtr form. I hereby certify that the N•ell(.r1 was(wen)cunttm+ed on aav:nnbnce
7.t►this a repair to an esisltag well: [�Ytr Or �NO *ahh 13A+1CAC 02C.0100 or 15A A AC 0.'C:t1;t10 HiU C.""arutrvc+n++r.�turn/onlf anJ+hut a
if#61,tr a j,"I1r/ill net Ailarn well ta+utructtnn Onfr)MVUOM sent ealrtaen fhr Ia tUrr njthe cirpy of An recurd hot been pmvidrJ to the mr11 nwncr.
relater rmlrr f11 rMarb arrxinrt or oa the tbrA r jrhtt J+erns 21 Site diagram or additional util details:
E.For Groprobd01rf at Closed-Loop Geofherraal Htits haining the same You may use the back of this page to provide additional well site details or%%ell
construction,only I GUI-I is needed Indicate TOTAL.NUMBER of hells construction details. You may Asa attach additional pages if necessary.
drilled- SUBMITTAL INSTRUCTIONS
9.Total well depth below lead surface: 154,t (M) 24s. f"yl Hells: Submit this farm within 30 days of completion of well
14or mulpple"rlla lnrall driAs Ifdi„d'rrrnt r AaWr•1g;100'md 2 lM) construction to the following
10.Static water levti below top of rosin=: (ft) Division of Hater Resources,information Proctssi"g dale.
If MuterlrvrJit above ramog.wr"4 1617 stall Servict Center.Raleigh.-NC27694-16I7
o
ll.Borehole diameter: (jn.) 24h For toted n�YeItr. In addition to�sending the form to the address in 24a
I2,14'tll construction method: (Iz C above,also submit one copy of thi form within 30 days of completion of well
-._1i consuuction to the following:
(i.e.suitor,votary,cable,direct push.etc.)
Division of Water Rtsourcts Vadergruund Injection Control Program.
FOR WAUR SUPI'LX'WEL S ONLY: 1636 hisil Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of itst: 24c. For Hater'Cunnlrlfc lnleeItInn Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection tape: Amount: completion of well cortstruction to tllc c ty health department of the county
oun
»hcle constiuclod. ;
Revised 2-22-201b
roan ONNI.1 NMI%Camlins Depwuuem of Environmental Quality-Division of Water Resources
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