GW1-2021-04157_Well Construction - GW1_20210827

WELL CONSTRIICTION RECORD(GW 1) For bdemal use Only
1.Well Curator 1Bformanoa:
PF%L►,o � �Q� i� 14WAIMZONRS
wan z � TO B�1 MOM
...a, -AD &P h'1
-3S 41 a IL
NC Weft Caofatora�safi=xombw 15 ov188 r•. aaaNlrrasea Hell.tDR i.� Mcaw
14 en5 l"`; W 11 'fir t 1�1 YkA \yIc,. ten TERIAL
CoMPMyNam M n ro ,t nr�� �
16.i1OMCA M 1[!i@iG
z.wen manPe rmsit A: a 6 3 t 10 MATERIA1.
Lida ffWp Ucublr urn prnn0s ris=COany,saw vacs Pwv.etcj g- fL to
3.Wes tlTse(eheekwdl use} 8' to
water Supply well: �To >►I►sm'M sLo SM Ta1�gv t►1A 1
Iic U e. a te.
�Y) MRwidewid
,W�SP19( ) a. IL is
Water�*(� 1LGRour
PROM rn as>oraOAt. tOMAt�rrsDaBQcADFOUNT
Non-Watersapplywen: ft. -P WM
Montormg ERecovay �- �!)
Injection Wen: R
Recharge
IA:SANWGRAVlB.PAt3i
Stange and Recovery FROM 170 ALl��o®
Test IL
Technology �Subsidtmoe Omdml o-
H=(Qoaed Loop) ❑T 20:1/1lIIm.�1DG mum*nowdismat dwft it
(H mgRdum) r3OIher(espbrinender021Remaft) AWK TO aeler e.ihret
C) p
4.Date Wes) $ �5^ a�a 1 Wen Rw a�a,b3 ft- 5 aIL
sa.Wen I.Matka.. ft
IL
m to - 'k'�f
�A��Y md7* tt. r..�SiR�
/� \ 2LB)R1lARSS tti� .:i Y1
County P�oei Idaaei5cnioallo.(PII1)
Sh.Latitude and longiaode in degeeeshulaeha/seconda or decimal degrees:
(well fictd,aoe is saffieiem) j/pO. Certification.'
a . *A-7 7� N l ;jS� —I-71 W — g tea,
&Wan)the weR(sOfamanent or ElTeatporary
Si�eaf w� Date
B3 d�++8 olds fo�ee.1�Y a+'+�'P d�die wall(g)was(wer+r,)aowAruded in aoaardeala
7.Is this a repair to an txbft wen: [3Yes or [ONO wUh l9ANCAC 02C.0100 ar ISANCAC 02C.02W Well Cbmwuct= and dud a
ifdds a a np w.fi Ow hMM wef/CMU&udfm&Onxc t-unitexpfnss dw ra Ww 4V he aopyofdW.v rd hw .barn pmv*hdto dw wwHOwner
npai►under a121 saseaxsedim oran dmba&*fd*fanw
23.Site diagram or additional well detail
&For Geoprob&WT or Ckwd4.oep Geothermal Welt having the same You way we the back of this page to provide additional weH site details or well
construction,only i(Fw--i a needed. Indicate TOTAL NUMBER of wells construction detuhL You may also attach addameA pies if neoessmy.
drined: SQBPAIDMAL MU-090M
9 Total well depth blow land anrfircc b s lam) ?Aa.For AR Wells: Submit this form within 30 days of completion of well
Fbrsadtipfe was lint aII depthr jrd (exmwrple-3(tj200'and2WtlDl *onsauction to the 8o11ow OF
10.Static water level bdow top of easing: 010 04 Division of Water Resources,h&rmation Processing Usk
if water level itabow easing an'+" 1617 Mai!Service Center,Raleigh,NC 27699-1617
1L Borehole diameter-_ (,¢ 2466 For IBieei=Wens: in addition to sending the formto the address-in 24a
12.WeR coon 14-1 R i n O — l aho submit one Dopy of thisfKm within 30 days of completion of welt
(ice som aK9.c posk or) 000strtralion to the tolloaviog
Dh4sioe of Water Resources,undergroaad Injection Cbatrol Program,
FOR WATER SUPPLY WENS ONLY 1636 MwA Service Canter,Italeigh,NC 27699-1636
13a.Yidd(gpm) C) Method Meat: 1 24c.For Water Sonar&Infect"Wells: Ta addition to Seadmg the form to
LL the addnns(es) above, abto soa 'i" ne Dopy of this form within 30 days of
136.Mbuftellon Amount U Z. completion of wen coestrudian to the county health depattmeet of the county
whore conshoded.
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Fame GW-1 Nw&Cmo)ma Depmanaat efr=6nmmeaut Qualdy-DWisim of Watac Rnmmes Revised 2-22-2016
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