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HomeMy WebLinkAboutGW1-2022-06195_Well Construction - GW1_20220620 Jan. B. ZUld IU:7tlRM tnV. Heal(n _ luo. 0111 f. I WELL CONSTRUCTION RECORD(GM-1) For Internet Use Only: 1.W t Cootracto�lufot'maUo�n: _ ' fr• J `� ���` WMAM- -ZZt1NfSc._m:�rx_s ;-.ice-_•u mr'' r=.mac.-.�.,'�,.'z x- -=— f b ggOM TO DESCRIPTION Wdl ContraemrName r2V d050' 2 G NC Weit CoinacYorCenificationNumber j :.q pFl� S[Nti'f6lrmulN'""i8-eIIs:ORl;IlVER •a"h�ahte "v^mot i FA ht TO DIMIErER THICIMUS MATERIAL /YS .i�f? ct bra '� l/� • _ � 1 � •�7-Well Construction Pernutff: oC ::1 cIlVNSiN'S.ASIYCii.OA'CUDiMCvi ""thun`itil:ctui6d:ttf"n'•.<•�,+erri:�,-�•�=� , ✓ d FR011 A TO I 01 Mir I mite m araTvnr,t klrrot(applim6tewe17eo,uurreGonpe artu P.WC,Comuy,SSmc,Yarinneo,ex..) (t ft. tD' 3.Well Use(checkwell use): D. kn ter5D i ell: ,PPYti'F M0\r TO n16morrA SLOTSIM6 T lgricuttaral icrpallPublic 0 R. rt. in,eothermal(gmtinglCeoling Supply) Residential WaterSupply(single) ft. IL mme dustrWCorcialRi t10R MATERIAL Z ACF�IEMMEMOD&MOUYon-Water Supply Went -,,, 4`a.Monitoring - QRecovery A injection Weil: n Aquifer Recharge �Gt�ppp ten Rlttredi�titr�±: ' __ _ • rf'1r rot,.,.c•-` �9:S�D1G1ti?lB)PX Fs•"Gfa61b:-�--,=:_.w=a;:��.L. _ Aquificr$tomp sad Recovery 0SalinityBan*%A,a0G FAO I To I MATERIAL 6DIPEACP.hr1T1TiN17A0n -� _AquiferTost 'C)StonnvualerDraitrege m Experimental Technology 13SubsidenceControl IL Geothermal(Closed Loop);. QTweerFRO=3RDA1L1;IN1GI15G.inl�iartdlttnniiiiliee�[tnc'cimo _=z= =«-= _a wffierawl(Rcating/CMlingReturn 01her lainanderp2l Rome" 0 R To fir DfSCAEFTrON rator,Iutdnras.solFratk :�rrt. 4.Date Well(s)Completed: D Well mo IL tJN 61 Ea.Well Location: fit dj fG �d�� Fa ciitY mo'r ifii ficab6 FaalityllTvnerName ( F➢ ) IL ft. P icat Addrau,Cil,sad Tip a��"� -�So3°�.1�°��' •�- ram, �--_=_==- =-_ - - -- - = � --- Comw PnrealI lemifieat;aallo.(PIN) 5b.Latitude and lotrgitude to degrees/minutea/aecouds or decimal degrees: (ifwaUHeld. larllangiss cleat) 22.Certification: 3 ,S,/ aoS � N l 310fIt" W • , : ,�- - �� 6.Is(aTe)tltetveli(S)ioPermanent or QTemporary Sigurare offttiliedWtUContractor Dato Byt gain&tlut J4wtrt I hereby eero rhor the wag)uos(were)emutmeted dt acotdoace 7.IS flrlS a repair to ao exbUng well: ❑Yes or MIa w8h 15AXCtC 01C.0100 or 1SANO1C 01C.0300 IMI Comintalon SlarxlRds and that a (lrhis is rspalr,fill ors tuowrwell waumction Information mrde:plam the narara ofte copyojrbu reaotd&t bren promfed to tbe:sdt otsner. rrpa rurz&r02!n Awk ration or on the baekofihtsform. 23.Site diagr am or additional well detalls: S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may usC thr,bacl-of this page to provide additional.dell site details or well construction,a*I OW-1 is needed.lndicato TOTAL,NUMBPR of v'ells censttuctiondetails.You may also attach additional pages ifnecrssary. drilled: SUBMITTAL ImittlerMIYS, 9.Total well depth below land surface: (ll.) 24o.For all Wells: Submit this form mitltin 30 days of completion of well Formulaple wens lurnll AW&V petenr(erz,ple.3@700'mtd 2@100') construction to the following 10.Static vyater level below top of casing: (n-) Division of Water Resources,Information Processing Unit; lfxmer level trauma uu1H&use"+" 1617 Mail Service Ccuter,Raleigh,NC 27699-1617 IL Borehole diameter:�(In) 24b.For inleetlon Wells: 1n addition to sending the tannin the address in 24a above,also submit one copy of this-firm within 30 days of completion of well 17.Well construction method. mot' r l �l construction to die following: (i.e.suitor,ro[rry,cable.duvet parA eto.) Division at Water Resources,Underground Injection CantrelProgram, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Bateigb,NC 276991636 13a.Yield(gpin) Method of test. tlrr . 24c.For Water Sumily&Inleetton Wens; In addition to sending the form to /� the addresses)above also submit one copy of this form within 30 days of 13b,Disinfection type: `�1 r Amount: completion of%,oil construction to the county health department of the county where aonstructed. Form GW l NormCmihmDgm maetarFAviramneamlQtaliry-DiviiianofWat"Room= Revised222-2016"