GW1-2022-01175_Well Construction - GW1_20220121

<..-Pr iit:Form-
NNTLL CONSTRUCTION RECORD(GW-1) For Intmnat Use Only:
1.Well ContractorWormaiion:
14:WATER -
'�%• 1 FROM TO DBSCRIPTi01l
M o
15.OUTER CASING(for.multi-wsedweDs ORI�� Rule
NCrlellCc- —mrCardfic�an\uaaa NES5 MA
DLiniZTEK TffiCKTt�t7AL
I:FtOM TO �
Cayi3 ts_ \. 26.INNERCAGORTFIB Gt eatLermaYr3o5TEa7aL
FROM TO DiAn'lETP.R
.�,.Tvell ConstroLlon Permit#: - 4 ft. ft. �
ie UIC C"*-StaiK mr etc) 1
:rt alt IIRalicIIble off arsavctia.-.perrnitr{
3.Well Use(check:Well use):
17.S nrnmErEx Si.oTSrLE TffiCcnvEss nrnT>;Riai.
Water Supply Well: FROM To
1 ivlunicipallPulr&e � � �
-Agricultural
CTaotne_yal(Heatng/Coolmg Supply) Residential Water Supply(single) ft- ft.
usnial/CoLnercial Residential Water Supply(shared) is.GROTIT
�Iad MaT[�i. En»�c�tss�T�ona:avtomv-r
FROM TO t
Irri ulna ft "�y fL
Non-Water Supply Wen: ft
Moaitoring
Recovery -
Injection W aw tt
Agiuffe R.-h-ge GroundwaterRemediation
}� 14.SANDItYR2AVELPA.CK ff ble
Salmi Barrier rRohi TO
nAquifar storagge and Recovery tY fz tt
Aq �Test DStotmwater Drainage
M
Experi-eatal Technology
— Subsidence,Control
zD.DRFLE3FIGLOG attach additlmtal slueets if n ��: e. a swe:eta)
Geothe yak(Closed Loop) Tracer FROM To nESCR�ON(ccla' '
Geoteetmal(Heasiag/CoolingRetuin) fisher( plaiaunder(r2lRemaiks) ft: t ft
ft
Well M#
d.Dale We (s)Completed: . - M f
Y
5a.Well Location: ft. ft
--� fir, i
i�1 hl to Y 1 � xs ft
xcuiw:Q '1 e FacuityIDA(ifapplicable)
It �
p r.-.-s,Ci y and Zip 23.REhUPM
`auWty i Parcel IdentlfirationNa.{PIl�
5O.Latitude and longitude in degreeslminutestsu cords or decimal degrees: 22.Certifiration:
N
W
S i_ tune of Cetdfiad Well Contractor
Date
ri.L<(are)tttePsF (s) eimanent or Temporary igning thisform l luoebn eerily rhar the ueQ(s)was(were)constructed in and a t a
vrrall Yes or�No 15.4?VCAC O�C.010Q or ISANCAC QIC.OZQQ ilrelt Constnrctiaa Sondards and that a
s,Is this a-p to existing copy of ihrs retard has been pravided to the well owner.
if t_•
rstra 1iffr.irrjdrrmatia. expLsPn ilienature of he
ar or u e back a`tr'.irjorra. 23.Site diagram or additionaiweIl details:
You may use the back of this page to provide additional well site details or Well
&For Getigrabzl73l of Chart-Loo the sazz?e p Geotlierrna!Wells having construction details.You may also attach additional gages ifnetxssary
construction,O'►y 1 GV-1 isnecdea LidicaL TOTAL IvRIMBERofWells SUBNIlTTALINSTRUCTIONS
drilled:
9.Total well depth below laud surface t
l5 ( } 24a. For All Wells: Submit this form within 30 days of completion of well
J
For multiple weQs Gt yl d rs j ru;, =; ..at�-3 ga2QF1'IIrd?(a}IQQ I construction to the following:
1 (ft.) Division of Water Resources,Information Processing Unit,
io.Static water level below tog Of e2stng I627-Mail Service Center,Raleigh,NC 276991617
If4tRler IEL'P1 Zr IIDa:'e arSJ.y t5£"-,.
ii.Borehole diameter Cam) 24b.For In€ectien Wells: In addition to sending the fora to the address in 24a
r y above,also submit one copy of this form within 30 days of completion Of well
12.Well construction method: construction to the folloWiag
(i e.auger,mtan,r ble,dzect a<:ti e=7 V Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONZY:
2636 Mail Service Center,Ralelgh,NC 276991636
iieihad Of tut ?Ac For WVater Snnoiv&Inieetioa Wells: In addition to sending time form to
(13a.Yield(gpm) I the address(cs) above, also submit one copy of this form within 30 days Of
r, t Completion of wall constriction to the county health department of the county
13b.IIisinfeetian type: �'y' offirt where constructed.
r�.,,tmaDeoaii�tAtofEnviroamea�Q�ty-DivssionofWaterResoutas
Revised 2 22 2016