GW1-2022-01846_Well Construction - GW1_20220216

WELL CONSTRUCTION RECORD(GW=1) For internal Use Only:
1.Well Contractor Information: j
'ti h.5 le_L�_ 1 14.WATMZONES
WenConhaac Name v=p Oil+r ��v�"- FYOM 10
DESCREnWN
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`� FEBrtB 1 6 2t!�? bs ft �s (�
NC Wen Contractor Oat ifi�on Number
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Bn eel S ►'La �y.ti�,�s I+n r��n -IPA in. sQ
Company Name
16.1NNSR CAMG OR TUBM
2.Well Construction Permit//: 3 S 7 0 33 FROM 1O DL MUR MUC 1 M MATERIAL
Lest au aW aabre wa awnbadFon pvms(L&UIG County,Sri Varrama,etc.) n n ir<
3.Well Use(check well use): n fL m.
Witter supply well: IM SCREKK
FROM TO D7AMElEs SLOrs= MATERIAL.
artaaal QMuniapaVPublic U n n in.
Geothermal(HeatingCoolitrg Supply) Mitesidential Water Supply(single) n n hL
Tndastrial/Commetcial []Residential Water Supply(sham IL GROUT
Irrigation FROM TO MATERIAL MdF1ACnMEffN =0Ddc"0Vff
Non-Water Supply Wen: n- R eQ(I j ei1 (,v;yh
OR-- ' 3 fL a v n r Vl t k
Injection Wen:
Recharge �[]Gwimdwaba Remedia2ion tt n
Storage and Recovery []Sa>;nify$arricr F VM PACK L 119PIAC61Af PAWMEM
Test 0Stolmwa1crDrainqge n ML
Experimental Technology 13Sahsidence Control
Gw&=.al(Closed Loop) []Traoer m DRIIS IPiGI.OG attach add6onal sheets i[
Geeth—al(Heamng/Cooling Pd—) : 0thea( lain nadet#21 Remaft) FROM Ta. D> ILON coror,t�doar.maned s�do
l S,
0 n
4 Date wens)completed OC OAF. p Wen m# 3 S 7 0 3-7 /S "'n 3S ! YYJli ✓1° rTt i yL f ;�[ p
sa.well Location _._... S n-.. � "- sin It �`C�h l P- l�l)
, < r
Fac,7ity/OwnrrName Fac,7,tyID#f¢aPPficabk) n n
r
Pbysi.dA&h.s..Ci1N.&Zip n n
q N(0O1b q`15`3 21:RIMAMM
C—Ity _ Parcel Ideotificafion .(P"
51L.tAatade and longitude in degoe mranutes/seeomb or decimal dam:
(ifwen fietd;'onelat/taag is mt5ciea)
- =�Cerfflcafionv. :
3 4S. Sa-- N '7 FS. .So 9-2 R,
_ Ot 13, 1.ao
6.Is(are)the wens)ftermanent or..DTemporary S,gaatme of attfiod �C or. Dare
BY signing this form.1 that the wells)was(were)conttr,eded in accordance-
7.Efttits'a iepair&au cristing well: ❑Yes •or 129iVo with!SA NCAC 02C. OIC.0200 Well Conutruedon Standards and that a
Ijthis is a repair,fill out known well construction Wotmad n and esplatr_t the nature afthe QOPY ofdis record welt owner.
rq,dr under#2l remarks section oranMe6aatofMisform. .Site-diagram' _ tafils:
&For Geoprobe/DPT or Closed-Loop Geothermal Wills having the same You-may use the. Me additional well site details or well
construction;:oily 1 GW-1 is needed: Indicate TOTAL NUMBER of wells construction dew ditional pages if necessary.... .
drilled: rj
SUB AL IN
0.Total well de th below land surface: 1 t0 ( - Us.For All Wells 30 days of completion of well
For malttple welfs list andepths tf�ervtt(eomnple-3Qa 200'antl2(a?I00) lion to the fo'
10."Static water level below top of msiug: 02 (il.) of _ Unit,
If water(eve!is above casing use"+" Division 1617,Ma$ a 7699-1617
il.Borehole diameter..._. . (�) . _. .24b.For Infection Wells-.In to the address in 24a
M Well construction method: A71 P RO(-6 R� tabove,.aLso.submit oneCOp}!o `f completion of wen,
construchon to the following
(,.c imam,rotery.eable,dues push.etc-)
Division of Water Resources,Undergro I Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matt Service
.b Method of test t 24e.For Water Supply&.inieetion Wells: )a
13a.Yield(gpm)
the addresses).above;also submit one copy of M rmy, --- _
136.Disitlfection type: Amount: .�i, completion of well construction to the counly health
where constructed
FamGW--1 Mw&Caw%na Depadmea afEnvhvnmcnW Quality-I ofWAwResoa,oes Revised271-2016
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