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