GW1-2022-09337_Well Construction - GW1_20221007

'ELLt CONSTRUCTION RECORD
i Tws font can be used for single or multiple wells For intetoal Use ONLY:
1-Well Contractor Informatiou: ' I
• t4.R'XTER ZONES I -
WeU Contractor Nuns FROM TO DESCRirRON
f 7oft /84a fts-
NCWellConhactorCatificationNumber 2,6oa ft
p� I5 OIITER.CA5ING fortfnul .]veils OR• 6
l3a rnette Well Drilling, OnCa FROM TO DL+MEfHt R`tfa ticY6te ..
ASS M A
ft 'tlatlAL
Ib.II1lYCIC:CASIiVG•OIC7'OBING eotliefrliialeiasadd
2.Well Constriction Permit#: RROld To DUt1tErFg
List all applicable uT11 comiraction ft R T�CIaYE.53 MATERIAL permfu(%e. marry,Slare,1!anatrce,etc) in.
3.Well Use(check well use): ft tt
in.
WaterSappiyWell: T $CRcEa.-
OAgriculhlral PROM❑MunicipaUpublic- ft TO DIAMETER SI+OTsME THIC[CNFSS SfsTERUL
ft
DGeothet'mal(Heating/Cooling Supply) L4RLggential in.Water Supply le t❑Industrial/Commercial pp y(single)) ft i
OResidential Water Supply(shared)
Ohri etion PxoM � �tA�L . .. -.
Non-Water SupplyWetl. ft �—� ft §and/ EMPI'tCEMENIMMOD'&ArdOUNT
meta our
Monitoring ORecovexy ft
lnjeclion Welh ft
❑Aquifer Recharge R R
❑Groun'divaterlterriediation .Y9'SA11j;pA. �f. :tiCiitite
❑Aquifer Storage and Recovery PROM To
OSalinity Barrier rtrAxF�uAL
❑Aquifer Test ft ft FMYLACFMPNTMEDiOD
❑StonnwaterDrainage
[]Experimental Technology ❑Subsidence Control ft ft
❑Geothe[mal(Closed Loop) OTtacec :.2ti I1121GLi1+[G'I;OG:aitaeli, iti6uiitatieecc:itutclssg
❑2wthermal(Heating/Cooling Return) DOtb FROM TO DESG7tIp1gON mler 5ardn soiUroek :: ;
er(explainunder#2I Remartcs U R ft 'u a�
S t'e h
4.Date Well(s)Completed:�ZLfj�Z�VeA ID# �,./' � ft Q it
Sa WeA Locatjon: It
� O t
Clvt'¢-/es �dC � � ft oft .
Famhty/OwnvNamc ft ft
� Fadility ITJk(ifdpplipble)
67 1 e tr�irU1-�!A ft ft
Physical Address,City.and Zip ft ft i`
T IF Z S D A.,-? -
County ;:.'.:.. .
Parcel ldenttfieahooNn.(PIN) -_ .
Sb.Latitude and Lottgitudcind in„r;,i:,;!i.:; >.-. ..,� lsr ,
(-INN field,one laMo °uuu / OOdsbr derimai egrEeS; 2Z Cernfrcgaon:
Mona is sufficient)
6'Ls(arc)the W.tll(s): l3viemanenY. or OTemporafy 'R'z"u=ofC U fie4 Well'Contrnttor
Date
7_IS this a repair to an exisiing,weU: pY ts or By slgaingibu farm,I hereby cerrijp Aw the•weU(s)war(welt)contracted in aarotdanct
L�fQn wiflr I3i1 Ni'iIC 02C.0I00 to I3rtNCtiCOIC.020D We!!CutrslrucBoh Standandr turd r/rct.a'
Ijrhfs is a repair,fill oat brown well eonrfirretion itfbrmalion and
^rltairrtader37l retnarkrse�tionarontbebaekofihlsform. -���'t'hrec�ordhas•beengmvldedta(hesyellowner.erpinfn tlrt nanmc ofdre ,
.Site d'iagttm oradditionalwell details:
ti,Namber ofweUs constructed: You+nay'US6 the liI of.this page to provide additional well,site details er well
For muftipleinjectionor non-1t,a upplyweUsONLYwtthnc�sanrtcottttyaeGon,y�� con��ondetails• You may also-attach additional submironejortt� pages:ifnecessary,
SUIIIKMAL INSTUCTIONS
9-Totafwdl depth below land surface:_ d
Aormrdtoewellshalal!depthsijdifferetrt(eornple-3(a)9 ^ e2 00j (k) 24a. For Ail We1Lv Submit this form Within 30 days
cormtj ec loll tothe fo7iowiirg: of completion of well
10.Static water level below top of casing: �i5
ruater level is above casing,use"+" (M) DivlsionofWaterQuality,Information Processing Unit,
11.Borehole diameter.
I617 Mail Service Center,Raleigh,ATC 276994617
f n') 346.For Inieetion.VRelis: In dddition to sending the form to the address in 24a
12.Well construction method: aboves also submit a(copy of this lbrm�within.30 days of completion o€'well
(i.e.auger.rotary.cable,dicer push,ere) canstdidion to the following I-
FOR WATER SUPPLY WELLS ONLY: Division of Water Qaality,Uadetgioaud Injection Control Program,
1636 i►7<ail Service Center Ralegh,NC 27699-1636
I32_Yield(gpm) Method oftest: Blovvn20 minute 24e Foir W i er.Sunoly&Iniectioh Wdlr'In addition to sending the form w
13b,bisinfcctton type: HTH ZD� thtd address es( )above,also submit one copy of this foim within 30 days of
�lmonnt .� coipletion Of Well construction to the countyhealth
where constructed. department of the county
Form GW-1 North Cantina D ePartmeat ofFavirouatent and Natural Resources_Division of Water Quality'
{ Revisal Jan,2013