GW1-2022-09179_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD F
Tins form can W used for single or multiple well.;
i
).Well Cuntracror Information:
J FROM TO I DESC1itPTiO\ �
Well C'ontracror Name ft.
Nc'Weif Cortaaetar Cenitieuion Numtber OEM To 314mirrim LII1E L
n. , a� y
Compact Kola: ` 16.tAtN£R
MO
DtAMitTER TFftCiL�'£SS �'tATERtAL I
2.Well Construction Permit#: W ft. ft. "t
1.1.,i rill oppkwhlr aril crraslructitai permits fix.C'ouag•,Stare,lrartoncr,etc./ Pt. ft.
3.WelI Use(check well use): 17 SCREEN
\Pater Supply Well: FROM T DiAMETER 5LOTFEE THICKNESS MATERIAL
j::.lAgrieuttural tSMuaictpailPublic fr, fa is
0Geatherinal(FeatingtCoolinz Supply) // Supply t }
sidenttal Water Su t single R. ft.
73lndustnaliCommerclai CResidential Water Supply(shared) i&GRtJUZ
OM TO MA 1PLACEIK ir. ETHOD&A.NOUA4
i�Irrtaation
j Xou-1ti'rter Sttpply\�'aN:
ft. ft.
'�'V1tNiltOftng QRarovery
Injection Well: ft. fL
Aquifer Recharge cGroundwater Rcmediation 39.SANDIGRAV$l.YACR if
j CAgwfer Storage and RCCovely DSalinity Barnet PROM TO MATERUL E?tP LYr3lETH00
ft. it.
i
iClAquiterTest uSiormwaterDrina_a
❑Experimental Technology -OSubsidenee Control 28.DRILLING tAG ateatb addidonal ifneea
Geothermal(Ciosed Loop) OTraoer TO DESCAIPi70\ tamr.trar�as sat7heilt •rainsre etc l
fa
i CGeothcrmal(licatirts Coalmtx ReReturn) GOther ttt 2atn under d2l Remarks) ft i
ft. fL i
4.Date well(s)Completed, ft. ft.
5.Well l ocado,: ft. ft, OL
ft. fr. e tm s 9� •'
te:Namtr Facility ID=(if applicable) ft. S�7P 3 .
p ft. fL
Pit ;ical Ad Tess.Cn%,Ind Zip 21.REMARKS weer .-f:^.; >
C'uw;u. Pared ldentitieatic Ko(PINS
Sb.Latitude and Longitude in degreeshninutesisecouds or dtrmat degrees: 22.Certification:
(,C%%elt field.une?,It long is suf'fietete) _ �• _�`� A - A ry
Signature ofConiSad Well Contraclar Date
6.1s(are)the wel)(s):iPcrttlaneut or MTemporary gy sigtnng this•fonn.thereby certify that the u•ell4i ttaf(n'eret rfultlruurd rat rreivrrtluntr
a'ttit 13A.NC'AU H.W.414a nr 1SA At•At•42t' rl2itri&,elf C'raxtrrruma.Gutr hrndt afro//tart o
7.Is this a repair to an existing well: ❑Y!S Or �.V0 arpt 0 thit retard hos hers provided to the u rt/im-ner.
//curs r.,"rerom t/aw kaauw well uairrrretatm Wfuraronva and"XPI'do the ownre al Ike
repair miler,.21 mmarkt.tecrtnn or an the hack of this thrill. 23.Site diagram or additions}wet/details: Affh
You may use the back of this page to provide Wdittonal wril site details or%%Yli
S.Number of wells constructed: construction details You may also attach additional pages if necessary
/•br malrrple mtectu:n ar awr•ttoler.turrly a ellf 0M.Y m•tth thr some c0Mfr c*in.ynn curt
mhnul rrav faint �j f 24.Submittal Instructions:
9.Total well depth below land setrfaee: ��J (ft.) 24a• For All-Wells: Submit this firm within 30 dais 0f curiIt ca011 of%tel(
Few aialnrltl a,41c ho all drra&it drArreat feinno rh••3@20i'oriel2r IM-1) construction to the following '
1 0—Static water level below top of easing: W[ , ({t,) Division of Water Quality,Information PrOc!sslltg Unit,
!l„ur.-r hovel
1617 Mimi Service-Center,,Raleigh;NC 276"4617 — - - -
t
1.Borehole diameter (in.) 24b. For t ieetion Welts: In addition to sending the form to the address to 24a
) .' —�---
above, also submit a copy of this form Within 30 dais of cumplrtror: of%veil
.2.Well construction method: An fa r u construction to the following.
0 a aul cr,rota•.cable.dtrc,:t push.etc.) Division of Water Quality.Gndereround Injection(,oatrol Program,
I3.FOR CATER SVPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.1'ieW Method of test t t 24c,For Water&PRI—y&t;e0tbermal VI`lils: In addition to sendmg the form to
(gym) m the address(es) above, also Submit one copy of this form within 30 days of
}3b Duinfect§oasype: � 14131't1'1C_ Atuouat ._ completion of well construction to the county health depattntent of the county
j where constructed.
Fom G.W.t Vanh Catalina Department of Envitonment and Nat u it Resomtie6-Di%•laian of water Quality - ke%,sod Jar.2013