GW1-2022-06751_Well Construction - GW1_20220603

WELL CQ11tSTRUCTION RECORD fGW i� For .Informal Use 01tty:
1. ContractorhFormadon:
I4.WATtiItZONES
well ContractorName FROM ZTo DHSCR»+�flON
fL f
>JC Wan
rl
MEW
TO DIAM>>M 4'HIG�8g8 WATMUAL
COMPMY BMD fL in' r1 i
CompanyNtuna 'ei��(r
1b.IN!!11{1tt1 MC
MMMORTMBMM dosed
2.Welt Construction Permit#: Fltoae To DUVIEM MUCKNOSS MATEIRAL
List ail appJtrxrbie watt canstrtrctlon pemdts(ia U1C,Cotmty,State,Yartatue,etGj ft. ft, i R6
3.Well Use(chwkwell use): it. R, In.
Water Supply Well: .SCRBST+i
TO Agricultural MMunicipal Public p fr. is in. Korg= MUM
aeothemial(Heating/Cooting Supply) DResidential Water Supply(singe) g. R, im
1ndustrieUCommetrrial DReddendei Water Supply(shared) A tiRBtTl
Irrl bn FROM 170 MATERIAL BMPLACE&NTMEXHOD&AMOUW
Non•WaterSnpp(p WeD: 8. 8.
lRa�,!T ft fr.
hoution went
AquiferRccherge �Gaoundwatertiernediatien ft
19 SAiVDI
Aqu1RTStwVandR cFvciy f3SalinityDiuricr M TO MATMIFAL t Aeee�rrc
Aquifer Test [3StonawaterDrainage fL &
$xperimentai Teobaology DSubsidence Control tt ft.
aeothemud(Closed Loop) Tracer 20.D GLOB atiachad tionaldmetsff
CieoHieanal Coo' Retum Other Iain under#21 Rcmadcs) FROM TO DSSCRIPrtox wbr tmrdn
ft. ft.
4.Date Wel(s)Compieted: WCU ID# FM o-
R-
tia.Well Lor�tion:
faculty! rName FacilityM#(if ayplic") ft.
Physical Addres4.Qtq,aadtip d' ft' u� 3 W
'o�y ParcelIdenffi atoniNo.(
Sb.Latitude and longRade in degreeslminuteslseconds or decimal degrees:
(!Ewell field,one Iatlloag is sutIlciem) 22. cation:
6.Is(am)the well(s) ermanent or OTemporary SigoatuleofCee6fiedWellContractor Data
�,./ BY sjBnWg thfsf M I htseby are dhat the w H(s)war(were)mzimcted in arm tines
7.Is this a repairtD au edsling well: are s or DNo svith 15AMC 02C 4100 orISANCAC 02C MW WcU Con9mcdon SGeadards and duff a
Ifthis Is arepatr,fill out Ano=well cm mcdon information and eaptain the row of the Copy ofddT recvrdhasbeat pravWdto ire well mvner.
repatrmder#21 remarlssecdon oran thebacl:ofthts farm 23.Site diagnamoradditiaital well details:
2.F'or GeoprobeMPT or Closed-Loup Geothermal wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER ofweHs construction.deta�.You may also attach additional pages Unecessary.
drilled: 1
GI U �aM><T'r,I�ny�rttyc-rr�ivs
4.lbtal well depth below teed sarfaca: M) 24a.For All Wells: Submit this form within 30 of coin letion of well
Formdttpk%wJls(!stall depths ifd fmW(a wipte-3@200 and2@1005 � p
construction to ttre foIlowing:
10.Static water level below top of eashW U (f!,) Division of Wales Resources,Iuformatioa Processing Unit,
If water level Tg above azsing,use"i" 1617 Mail Service Center Rat efigb,NC.Z't®9-16i'7
11.Borehole diameter. (fn) 24b.For-Infeettou Wallet Ila addition to sending the lbrm to the address is 24a
yy��
12.WeIlconsfroction method: tl ojac" abo%also submit one copy of this foml within 30 days of completion of well
G.e aomreran.eablr�dtrectpasl,era)
construction to the fbAowhtg:
FOR WAT1itiR SUPPLY SPELLS ONLY: Dl.9sion ofwaterReso�s,Undargroand I�aetioa Contro�Pi+ogca,,,,
1636 Mai!O"Ce E'mtw,Ral4,w$769N16M
13a.Yield(gpm) Me*Ddof Wt:AA&" 24c.Ibr Water Sbnoly&`Laiectida Wens In addition W sending the form to
the address(es) above; also submit one copy of this firm within 30 days of
13b.Divfafeetiou type: Amok D Gu e.B completion of well e=-nc"'n,to the
wbue constructed.
county health department of the county
FotmGW-1 NotthCerelmaDcparmneatofBnvironmaotat QuaFiry-lAvisionot'WatorResamas Revised2a220t6