GW1-2022-06483_Well Construction - GW1_20220706

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i
P1,int Form
WELL CONS••I"RUCTION RECORD (GW-1) For Internal Use Only:
I.Well contractor Information: s,s /\
t ✓/I r sons W:e-" ei .I C(t..JCe ��t I JD"i �. Ia�wArl R'/,()Nrs _.. ��� - —_—
bkcllC'onU'acb,rNatne _ __.._._ tlPlll)N _ '(..--
\( Well C'unuactnr Ccnilieali,u,Nuniltcr 15.OIIl ESR(:;ttiING(for multi-cased wells)OR LINER(i�Jkabl�e)
D real fl•:R 1ILINE :(ifi. m.
Company Name10.INNE
2.Well Construction Permit#:
451, A6q t/4:1,( PRUaI _ 111 Ill\Mf:InR _— IIII(KN6,NN DIA"I'F9t111 I�.
l.ict all nppin•nhle nett<r,n,u'ucrir•n prom,(i.r• UR. Irian, rrc.l '---
3.Well Use(check well use): fl. I.
Water Supply Well: "- 17.SCREEN ��
PltUdt 'ro ImmNic-11, SLOTSI%f:
tr.
Tf11CKM1taS �47A1_P:It 1:1�1.
Agriculharal E)Municipal/Public rt.
(icuthcrnt al(1lcafingiC'uulingSupply) QlResidcntialWaterSupply(tingle)
industrial/Commercial FIIResulential Water SupplV(shared) -!�'—
IN.GROUT
' IYYI'�ahUll _LKfPll —'1.1, nl.nrr.liilkl _rNl'1.4(:P;NIIiN'1'41P�r11O11.�n�_n� �r
Non-Water Supply"'ell:
IMonitorinu E31zecovel}" --
Injection Well:
ft. — ft.
(Aquifer Recharge [DGroondwater Remedianon
l9.SAND/GR�AVG L:PACK(if apj�licablel—i I_
!Aquila Sta•agc and Receives QI$:Ilinily 13arricr rito,l _j_rti — M.A.rr•.Itt:tl r:.�ii't..tcF�atF:�r ro1F,r717iri 7 ^..
Aquilur'Tcst Dstormwater Drainage ft. ft.
l:ixperilneolaI Technology Qlsubsiclence Control ft ft. --
Gx,thernial(Closed Loop) D'f racer 20.DRILLING LOG fatta-If additional sheets if necessary) ---
Geothermal(Iicatin'/(.'online Reualal) iruuat M DE ticRu1I ION fenmr.baton,,,onn�ii,L tt !�m.Or f-
--- 6 0(hherlexplaut under t..l Remarks) -'
4.Date tiVell(s)C'ompletcd: "'ell lU# J!� C' / AT IYO f(. Crre L�f�-�j�t y+✓_ S /t ' -
Sa.Well Location: fl' ur'r. Ct j
Iat.ifimOwmr Nam,. Pt flit., IfY,!Irfapph.nMcl /��� ft. -S'O It. f„)�r,�`� / Free•. ¢�'f�_�t��`_....
t'
--._......_------ ell
7�',.
3 � �. �s Ali,Az,,, Cat _ — 1
- - - - - -1
Ph I d Addre ('ily.and Zip ft. fill
21.11
I'mc.il ldcttlificamm No.(PIN)y- T(I°I �:>? t£� �•,,, xlS,t��d.�eb'_ /J'� G�-(% G!,?.
51).Latitude anti longitttie in deg recs/minutes/secon(is or deci III:lI degrees:
cII licld..nre lat lrm)t is suf icrcm) 22.('el
f 7 i atind:
(i.Is(are)the wcll(s)OPermaneuf or MIT'emporary
.'ignature nl l'crlllied l4'etl(.'unn'arlur f;+ I)a?e i�
IfY si,enhkt the,/arm.)1a•rrhr rtv-li/r Mae the ur•/(ul,reel, 1"".'vi r;gytrxrwd ur o;rcur:i!r•,rr
7.Is this a repair to an exisling moll: 0Yes or 0No ❑ilh 15.1 VC,IC a'(' Mlle ar 0A,VC,R n_C o.?no oi•0(>,rl,snan lfnn Rramlard.and 11"I it
//this ix a npam rill ant knonn utdl,r"mirrrrlinn in/ornwrian and rsp/aw the as m-e of file rope a/this rewind he,.,h,vn prneirlrcl a,the nrH none. .I
repair and-r'I:/ron"reo.werinn ar nn A har'b ul'thr.r lin'nr.
23.Site diagram or additional well details:
S.For(;enprnbe/DI'T or(losed-Loop Ceorhertnal Wells having the tame You may use the back of this page to provide additional well site details of tilcll
construction oniv I OW I is nectled. Indicate VOTAI.NUMBIT r&wulk construclion details You Ina\ also auach addi' akin it A49 wear
drilled:_._ SUBMITTAL INSI'Rti('I IONS a b
9. fotal well depth below land tiurftce:• �� �(fL) 24a. For All Wells: Stlbaltlt this1ibrnl within 3 � kty'N t won {��]i n of fl-cll
nntbiplr t c11,list all depth,d dil/rr nil rr.nnnp/r• {(a-_'00'rmd.Bee 100'
conslniction to the lbilowu,g:
11).Static water Ievrl below-top of casing: _ 25 (ft.) Division of Water Rest Urces,1,109FAloolmra.'` IIg UD
1i t:vrr•rIr•t'<'!i.,•aharrr:,sin?:.tr,r 1017 Mail Service O,,1 r,Raleigh,N( � I
11.Borehole dianu4cr: Q:) (in.) 241). For Infection Wells: In addition to sending the ilium to the address in 24a
above. also suhrnil one cup) of This Ginn within 30 days of completirnt of•:rcll
12.Well construction method:_•_,r>t'>✓1./
cnnsn'uclion to the following:
U.c.:utRcr,nrt:vy.sable.ditact push•rtc.l � I..
Division of"ater Resources,Underground Injection Cnntrol Program;(
FOR WA"Ph.12 SUPPLY WI?I.I,S ONLY: -~ - I636 Mail Service Cimter,Raleigh,NC 27(,')9-Ifi36
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13a.Yield(gpm)� Method of test:_ _ 24c. For Water Sunnly& lnfectitin Wells: In addition to sending the form to
the ❑ddreSS(cs) 11.10VC. also submit one copy of this form within 30 dayt:' of
131t.Disinfection type:—._ __ Antolini: conlplclitnl of fVcll ,:onstruction it) file county health depanntent of the count,'
Where cunstt'ltoloci.
I nrtn f i\1' I Noll[I I. u!i,fa Url,:;meni"!'I n•.l moil(.f11;0 Quair, -DI,im,m"I'\\':d,•t Rc,m",� Rc,i.r'ri .'_..'.•Sl(t,