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:
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3.Well Use(checkwell use): D.
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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:
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Aquifer Recharge �Gt�ppp ten Rlttredi�titr�±: ' __ _
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Aquificr$tomp sad Recovery 0SalinityBan*%A,a0G FAO I To I MATERIAL 6DIPEACP.hr1T1TiN17A0n -�
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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
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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"