GW1-2022-05906_Well Construction - GW1_20220627

Jan. Z9. Md IMU M tnv. Health No. oil i r. I
`r WELL CONSTRUCTION RECORD L 1� For internal Use Only:
1.W4CGntrActa)r.Iuformatto"�� t=WAVIfrzortas.:=_
Well ContradorName FROM TO DESCR ON
h ft.
NCwellCoaoncat Certification Nrrmtxr left)IITEIC'CBSI,SitI'fri�midiita`se3- lis'OFFIEIVSR' fa lt�n6tb 'z.^?s� ,;
1bQ�irS f i 1r�l l G?,� S�P7li`_ FROM TO DL1h Tff[=Ess AWERVIL
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corn a —c rr. a 5 -1 it s
1 IVNE1s CASLYfikOit'LtID1PiCw: '"thern`id[rTdioda�"`u.�:.:i •t- ='f:
2.1Ye11 Construction Permit#: GI ,� FROM To 0rAlr1LIMM TSICRNEss MATEEL1r.
Lruoll appl cahte well em,rnuetienpem,tn Ile.UIC.COWW..S4atc,yarimice,arc.) R• ft. In.
3.Well Use(eheckwell use):
1Yeter Supply Well,
FROUr ITO I DL MER `SLOTStZE�••T rt - ESS ~ MATERIAL+
Agdcutmral MMunic" blic 0 Q. R �.
Geothermal(HealindCeoling Supply) Pdential Wamr Supply(single) n tL is
_IndustrieUCommcrcial Residential Water Supply shatid ---- -— __:
uPP Y( ) - --- - - - _
-
-Irrigation FROM TO MATERIAL - EVPLACEMENTNETHOD&AAIOUNr
Non-Water Supply Veil• rr �p f6 ' `v' aL
Monitoring �Reeavery n. rt.
lExperimental
ectionWell:quifer Recharge [jGmundwnterRemediWan
]QSi1P11)IG11SVEL-PA f%'rrablE i_quifcrStomgeandRccovery �SaliriityBerrier FR0:11 TO sL�TERIAt, EMPLACCAyENcMr►NotlquiferTest •E]Starmtvater Drainage IL fTechnology OSubsidenceControl m. it.
eothermal(Closed Loop).. OTraeer -3asAR>zIIA`Gt3GieotherMl(Henting/Coolin'Reft M Other in irnder#2L Remarks FRO51 To DFSCatPrtDN cotar,hrrdnur,ralthnck , shr eir.)
G [r. R -e
d.bate Wells)Completed:Well ID# O h �off lr
5a_WcllLoeatiaa � to G lr�
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Faa7itylOwnerName Faeitity1D11(ifiiDytieable) ft.
physical M&.S,City,add Zip
r
County PmralMeailfiatidoNo.(PIN)
Sh.Laiitude and 1010tadc in degrees/mlouteslseconds or decimal degrees;
(ifwali Held,"a to sa suSeieut) 22.Certification: -
3 / 1<7 &)-2 N �l1 ��2 - a &IW
6.18(arc)theweli(s)IOPermenent or [Temporary ftruntreogetniffedWenContriclor Dato
By rigning dJt farm I hereby eer0)y rhor iha irell(r)i„dr{were)eetrruuered ai aorarrlaace
7.1s this a repair to as ealsdng wetie QYes or QNo with 15d XCAC 02C.0100 or 15.1 NUC 02C.0200 lWrll Connnietlan Starm'ews and that a
(frhisrswrepay,frRoralmomt well waama4rr[nfarmaria,airderplarn the rraumroftha coaofrhtsrcmrdlmasbeeapiosydtdtoI&Velloxirer.
rapairyndere7/,rnrarkiarianoranrhdbaeFaJrhssfarm 23 Site diagtamor additional well details:
S.For GeoprobeiDPT or Closed-Loop,Geothermal Wells having lhestune You may US;ttrq back of this page to provide additional men site details or well
eonstruetion,onlyIOWlisneeded.]udicata TOTAL NUtulBHRofaxlts coltsttuctiondelails.You May also attach additionalpages;fnecessary.
drilled: SUBN=AL INSTRUCTIONS
9.Totnt well depth below land surface: o� ([t•) 24a. For All Will Submit this fiama mithin 30 days of completion of well
For m:,InplemC4fixrall (aarnpla.3(2O�2@10&)
eatmsuircrion to the following:
10,Static water Itvcl below top of casing: ✓ (ft) Division of Water Resources,Information Processing Unit,
hrwararImaltsabamcartug use+" 1617 Mail ScMct Cchttr,Italelghm NC27699-1617
11.Borehole diameter. (11,)
24b.For inlec� ila�\Yells; fq$dditipn to 5ardurg the fann•to the address in 29a
Wellconstraei � obovc,also submit Dae copy of this form within 30 days of completion of well
(i-augrr,rosary,cable..le direct pmub,eto.) construction toiltcfollowing:
i.c. method; -
Dividan of Water Resources,Underground Injectton Control Program,
FOR WATER SUPPLY WELLS ONLY; 1636 Mail Service Centel•,Raleigh,NC 27699-1636
13a.Yield ,EEptn} Method of rest: .i, l 0 2de.For Wafer Sunnly&Infection Wells; In addition to sending the form,to
the address(es)above, also submit one copy of this fonn within 30 days of
13b.Disinfection type: r' Amount: C!!�, completion of well construction to the county health department of the county
where Constructed.
FarGW-11 Northam lIrmi3 pumuewctSwjmnmanralQuality-DivisionofWatcrRrsmmcs Iievisod222-2016