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HomeMy WebLinkAboutGW1-2021-01001_Well Construction - GW1_20210419 RE.SIALcNTIAL WILL COtiSTRccrtON RECORD tinrth(.soiIna Deaartmett:n7 Er viror mcrt;md Natum;Resaurces-Div�c.<r nF Watt `l1P.f7 W;ELL CONTRACTOR CERTMCATTTON a 1.WELL CONTRACTOR: 6 Q 1 B• WATER ZONES(dep4n). 1 L.4,5 Se-�I 7_ G6 To SO»om_-4L00F' C-. cap ___Ved Contractor(Indwi(luel)Name Too 9c wn TaS Brttrr^ ka,Q ley r 5 V 1 11-_ Uj LI1 Drl I l 1 h 0 f-T-N C. Top 8ott«n _ TOc Bottom Co•-tractor--omoany Name��{ IJ N)as �� "�' 7. CASING: Depot ` SWeight Material Street adrre44 ` {{ 7='Tb Bottom d d" = A Q .11 `�c ku I a r s U t !l g Top Bottom Ft. City Jr Town g State Z c Code _ _L Area code Phone numb- 8 GROI+ Deolh Materai�++ Men1x 2 WELL INFORMATIt'.3N: 'oo Bottom �-S R. '�NNi7c ? �. ,oN'STPUC7ON PERM T*la - o.�o- �c 1��g TBotmm OTHER MI ASSOCIATED PERTS#spy I -oo Bottom Fr SITE WELL 4)*fr av"biel .2) -2 2 S. SCREEN: Depth Diameter Slot Slxe Mat:el"181 3.WELL u3E(v,ed Aoff Dc *Box;' Remderdisi Water Suoay Ty B M=. `L in in. 3 LATE DRi�LED - 30 - �1 ToP Bobom Fi M T ME COMP ED . qb AM❑ Pep 7?' Top Bat?an in n 4.W6LL LOCATION: 1o.SAND/ORAvr=L PACK: DOpW Stne Material CTY M a t Cluj COLIN-Y e Q w Cu ToD Bottom F 1-2./5 `fY1 a 41 cn� W as c� C;rele _.1?& SQ Tor eotm-- S!rer�fi�rsx.PiiersDera Cogr m Sty,SLMMsion.Lcl No.,Oarcer i!o„o6e} Too 30ttOs*1 Ft -OWJGRAPH!C I LANE'SET'INGG (dxn*aw-w1a0e boz) 1 DR'LL1NG Lam.= _valley CPat ^_,Riwsge Other Tot Bottom Formation Desathon LA'TMDE 'DMS OR 3x.xx)OCXX DD LONTUDE DmS OR 7x.xxxxxx)= 00 / ZJ r'T• a U GI s c FBI LaIltudeolm o ude source. ]BPS i .TopoRraor 1W -- (x.c ,of%es must be shown on a USGS taro mac anafoMaaw to V•!s roan if not using GPM s.v#VLL OWNER. F z 4 4r alit Owner Name Street Address A ' ! n V VILI Gity or Town SIWR Do Code r Area COe Phorte rxwrriber 12, REMARKS: S.VV&L DETAILS: a. TOTAL DEPTH• Ll S15' -Ff b. OM WELL REPLACE DU.STUG WFLL77 YES NO ;DO HEREBY C,Rlm 'THAT TIHIS WELL WAS C c. Top o!CasiwtQ; Al -rf. ACCORDANCE WfTH I SA NCAC40,WELL CONSTRUCTION WATER LEVEL Below if ow To Top of Gasktg) STANDARDS,AND THAT A COPY OF TH)S RECORD HAS BEEN (Use L 0 DED TO THE WELL OWN IER. d. TOP OF CASff4G IS J Ff.Above Land Swface' 'Top of stior below tend strfsoe may require a vnrlana in aecoMa xw with I SA NCAC 2C.0116, TLIRE OF WELL CONTRACTOR DATE a. Y�LD cs ►: 5a a�,r+loo OF TEST i r f. DtSINFECTION:Type �'t Amoe>,tt Z C PRNJTED NAMESubm COtlS7 RUCTI WELL im. th&a 1XVNIM amew allowt de'jt8... AWh:i1t�AlIfOBiln , Form GW-1 t `$fllViod C '� Nw�� '.''Pt+oite'litx.t9' Rev.i I JIM