GW1-2022-08732_Well Construction - GW1_20220826

Jan. 29. .2018 10:580 Env. Health No. 6711 R. 1
WELL CONSTRUCTION RECORD(GW-1� For Internal Use Only: ,
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wellConatici rName - EROM TO I DFSCRIP7701Y
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NC Well ConnacarCeni6ceGonNumber '._IS:i011TEXCASLY[}:td;FinuD[<a5e3:vYeIIs:OR*EBi fii')Udibttlet=, r!;'
i FROM TO DIAMEIEE TH[CIClESS htATF1tTAL
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Comp (/ 7</ t: `Y
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2.lYellConstructlonPermit#: ! FROM I To I I-)WI a TWC3K0n;g9 suTEwAr
hlrf nil applicable well eaurraerioh.—In(t e.UIC,Comlry,State,Yarl-ce,etc..) R, R. In
3.well Use(eheekwen use): rt. - R. i°•
Water supply Well! :12:SCREEN.:¢��_•:�_>.._::::--::__......:_.:_.....--.......-.:.,-----.�:.—._
FROM 110 1 DIAMETER SLOTSIZE ThlCKNM f MATERIAL
_AgtiCUlN[sl rctpal/publlC ft.
Geothermal(Heating/CDaling Supply) _Residential Water Supply(single) it.
-
_IndushwComrrrcncial Residential Water Supply sharcd WHOU
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_Irritoation - FROM To Ii MATERIAr. M1FLACEMENr'MM0D&A5l(1UNr.
Non-Water Supply Wall tr. �So (6 �` � �I-
Monitoring ❑Ret Query R R
1-GeofficrinAl
ection Well: h, tr.
quifer Recluirge QGmundwater Remediatiolt
je
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quifer Storage and Recovery [3SalinityBearier FROM) To MATERIAL EMPCACV-11= 11011
quifcrTest -❑StormwaterDrainage n
xperimental Technology CISubsidenceControleothermal(Closed Leap) ❑Tracer =�O�D R3:flG aiiad,eddlttohatvhee6:lf'nrciota(Hent;ng/Cool ngReturn Other lainonderli2l Remarks FROM TO DFSCRIP[rON mlor,hrardncL%selVrock M,tri..io:e e1c1
4.Date Wells)CompletedtJ Sa, Wellmm It. �D ft
Sa.Well Location., 71J0,
Ge—,I y . J? �r/� it ft.
Facilily1014herNaol& - - Facility 09tifcpplicablrs) IL R.
'Phys Adana,City,add Zip b M
County Pe,eal ldent;6eation No.(PINj
Sb.Latitude and 10ugllude in degrees/miautes/aeconds or decimal degrees:
(ifwallll Hold.one 1a01onnggissufficient) �( Q r� 21.Certiration:
N V /aO� �o/O W
6.I8(Rre)[be weli(S)IOPermanent or ❑Temporary Sigunire oteertiliedWellContraetor Date
By Q-4 ddr forha 1 hereby Cc*char tha wel!(s)was(here)eahtnreted m accotdanca
7.Is this tt repRlr to aD existing wets: ❑Yes or QNo with 1Sd NCtC 02C.0100 or 1S.r X.W 02C.0100 Mel!CoAnnnulon Slarkfowr and that a
{/ddslsarepal,frfiombraasrwdieamtrucriorrinfarina/ionmrderpfamthenaarroofthe copy ofrhts&widhasbeeuprotldedroMeirel/owner.
repair under e71 remarlr seciian area Ilia baef oirift form
23.Site diagram or additional ive11 details:
B.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use i1n;back-of this page to provide additional well site details or well
eonstmetion,ouly i OW-1 is needed.Indicate TOTAL NUMBBR of wills construction details.You may also attach additional pages if necessary.
drilled S11IIMITTAL iNSPRIICIL0 _
9.Tarn[well depth below land surface:_ � A) 24R, For All Wells: Submit this form within 30"dsys otf c3mpletioil.of 'ol4t�`
For mulaple Wells lur all&PAS;f&fjaear(emmple.3(200•and2@10f0'•) construction m the following:
n
10.Static water level below top of casing: � � (ft.) Division of Water Resources,InformRilort�rd ' -9 11enit?022
lfrrarerlawf irabmecruwg rua+" 1617.fail Service Cchfcr,Ra e! NC 27699-1617
1_ 754SJr'-1 P!a'l..K".Y�ji�t'�,[t''I
11,Earehale diameter.�r(in.) 24b.For infection Wells; In addition to scndntg the ib(m" ess m'2VTft
�!^ �p�� above,also submit one copy of this Than within 30 days of comp1 11OR of well
12,Wellronsttcabl, method: !\�'ttar 1� construction to the following:
(i.c.auger,rotary•cable,direct pusl4 eto.) -
Division of Water Resourceg,Undetground tnjeedon Control Program,
FOR WATLR SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigb,NC 27699-1636
13a.Yield(Epm) `/� Method of cast. Jr ' rl 24e.For Water Supply&Inleetton Wells: In addition to sending the form to
_ the address(es)above, also submit one copy of this form within 30 days of
13b.Uislnfeetlan type: I f Amount: 3 completion of well constuction to to county health department of the county
_ where CDnslmcted. -
FormGW--] NoKhCamlineDeputmadtafFavuoameaarlQuality-DivisionofWatuRcromees Revisa 2-22-2016'
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