GW1-2021-00338_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD
7,Ica^ con be:x-d'or si::eie nr muhiF!:u'rlis
:.\V'el!Cuctractor Information:
It WATER ZONES
C! Iy) s tV41r Cr V a e�f FRDM TO DESCR!MON
<:-tyd:Cn:::rac:a Certificm:an r.:mocr 15,OUTER CASING for mote-en+ed wells OR LLRER ifa hle)
FROM TO DIAMETER THICR.hESS MATERIAL
.Q � F' Wel I `I�rt 111 rya o R. i
:'o-.Fan+:.;cc � 16 LN7\ER CASIF'COR 7i;BDh"Ghaetberaml clozd-laaol
2. ft�rDIAMECE�INM 1 .v.ATERGL
Well Construction Permit 9: J a I it
,, n:!^pra.mhl..:Jl omu:rueano:y,nnrs/:.e.:bo�n:5'rorr, Pmvant+ rrrl 4. � in.
3.W el I:se Ichrck well use): r7 SCREEN
' FRO{! TC DW!E.'ER SLOT512E THICKNESS MATERIAL
Water Suppl)Well'
II L•. fL . ie. I
/!�L EI/P3LL: is
�Cto z . al(Hea!i�g/Cw4.ro S-Pply) 9Ite me..ral Wet=Sac)'(single) fc h.
. I .n.
1n.dus;va!iComme:<1zi CResldenl:ai Walr Sapply(shared) J1 1&GROUT
FROM TO^TT MATI:RLLL L{:fLaCEME\T METXDD6 Ut Ol]T '
:cs¢arun ':� f:, i O•U ft. m1x ,�jsYQ
Sou-\Water SuPPIs'
;'ADnaonng CRecoven' �
injection WeL: i s ft. i
Rcohargc CGro,mch.atr R"Mcc:ah.o. +S SANWGRAVEL PACtifamlicsble`
FRO.Y. I TO N.aTERIAL £?tYl_aCLN E]T VEI XOD
_Ac...ter S:oraee OIL Recover ^Sahnin'Harrier
"fes: �-Slcnr vzter Ott:rage
fr
Ccz?er::tea:z:':chno',ugy =''Subidz.^a C'ece�:
26 DRILLING LOG( ttrth add'd 1 sheea if neaasarv)
.. (fused Loop) MT2cer li FaDM TO DESCRIP'I:0\froter.ha:d+�sod,nxk n-e,•nv,sae.act
=C=i!c-r•a'(FcatlryCco!:n2 Rea:-) Other(esplmn_nder d21 Remerks) fr.
a.Date VV'ell(s)Completed: IQ, Qoa I fr tc !—
>.Wei;Lacat•.on: '�. to R. I
for fr.
nae ZIP 21.REMAPW -
_ 3523 - `16- (ow
St. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certificati:m:
—06
��// S+muwre of Cznificd\Veil C'omracm _
6. Is 13re)the well(sh @Permioent or ❑Temporary BiI',ui -Ill n.I hrahr ...Nb/h.,r e Ill/+n..
// ,ua roA s.'�. OR 0101 J54MA(' no r:a< ,
7.is this a repair to an eaistingwell: .^ryes or V o <„A+q7 rn,.rcrr,Mha..hrr„I....,rl:d 11,rn;.rrr,:+n,n. ,rlNltt
,'I fill ,F .elle w/nrmouwn m,d..rry n,. ,re,rznna<,l rh
,;M„ -,,;, ;•„r h x u7rru,fr:.0 23 Sift dugram or addmpnal well de ails „ce `
' oar n, ) use re back o h s a e :o P r e aJ:i:t Dna lei _ _.. ter:'.
S. SLmDer of wells constructed I,ors:--ticrde:ails Yo_may a,soatmc add:..s:.Pages ,.essah
urn„n-1
24.Submittal Instructions:
/
'1 S to
C L^!s °,. : :r'.hut 30 cays m ;: u.: :a:,e'.I
9.Total well depth below land surface: �J ft.) 2ia. For An
For,-oh.,gc,„Alundldrp,h.✓,fifes faa,aph- 321of. ,... lUrh Co^str..^.,to tuefol!OWuiz
ID.Static water level below mp of casing: 3/ (ft.) Division of Water Quality,Information Processing Loit,
1617 Mail Service Center,Raleigh,NC 27699-1617
1:.3crehcle diameter: lY iIg (Ir.) 235. For Iniection Wells: in add!ion to sending the('ono to a:address:n 2:1
van a'so suomla copy or:-.:a :0. n a ,h:r 3U din S L _map
:2.M 11 cons:ructiOn method: Vln T Qr V v..,tr•.:c.:on to !I.fellow's
able.,;::C::p'dh.c:;
-' -• Division of K'a ter Qaality.Gnderground Injection Control Pragrn m,
13,FOR\WATER SUPPLY WELLS ONLY: 1636 .Mail Service Center,Raleigh,SC 27699.1636
: Igor yield m) ::\fethad of test: /y� ls- tF'1��(Vy� I lac. Far K'•re Sap Iv&C,eatberar al'A ell :11 add:Han to sead:ng:nc c;-;t•.
(gP ++'-'�—1 Jte aFaressate above, also subm:j one copy of th:s form w:Ialn 3' dzys oC
compietion of Weil construcQcn tD the county rcallh depanment of me coLntp
13b.Disinfection type: I�tIC f'lY1P_ Amount:_�5 rye�_! :vhere constructed.
Farm Gw'-I ].nh Cara!Ina Depanm<n of E,:vlr... a,,—M Nmoi kezmtax-Division of W::c:Q:csl::y 10!3