HomeMy WebLinkAboutGW1-2022-09983_Well Construction - GW1_20221104 51
WELL JONSTRUCTION REC01tD(GEM-1). For • ••
rittelnalUse Only ,
1.Well Contractor Information: _
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WeILContractorName
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2.Well Construction PermitM z d O I''3 �C) a �o}z TO. Dv►n�rER TznclaMss nmTERr v.
Ustall appGc bla ird l consducdan permits(Le.Ula Coanty,Stat4 lrarlance;eto.) ft: I,to:
3.Well Use(checkwell use):,: fa tn.
WaterSupply WeIIe
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FROM To I DIA11WM, SLOMME TMCIMMMN MATERIAL.
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Geothemtal(Heating(Cooling Supply) OResidentiol Water Supply(single) f
lndustrial/Commercial Residential WaterSupply(shated) ��{GRour.rlt!!!',>% d • 33{'"� � o rr
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atiGA� M O 1 MATERIAL• &AMOwn
Non-wa Supply well:
Monitoring Mftcoveiy
Igleetioa ell:,
AquiferItecherge 13GroundwaterRemediation.
arfei to eandReCOve Irt9aSANDlGRAVEiJPAl;1t?Ira`"]Imble Tex tst .;,a,I���;n: /Xa1g.ia- TKu�;}
Aq $�`` rag ry OSaiwayBamer FROM• TO MATERIAL EMFLACEa@ITMEMOD
AqulferTest' 13StomtwaterDminage ft ft
ExpedmentaMebuology r3SubsidenceControl fffi ft
Geptheffn4(Closed Loop) OTlacer `320.'DRILLING LOG attachsddt6Snn13beets"t[iieewa .re:L4 3 3a1t�aarli :
Geothemaal(Heating/CoolingRetum) Other( Wmundor621Rematks) mom To DESeR>ertOH eomtinnnta :owmrx - ei�
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4.Date Well(s)Completed:_S,-Iei'Z7—WeIIID# f` & I. P6
5a.Wzltlpcation:
XName _ FacW'tyID#(ifappl[eable) ,. :.fa rS:d'.2:!/iF/I l'.:��17r�' l.',��l r,1.4�Jl•L/ t� C'�z v t! j
p6ysteatAddnss ft andzip 2 Fw 3 1 e,
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Comfy Y=clIdeatifieationNo.(P� ' `- a V
6b.Latituac and lougitude in degrees/minutes/seconds or decimal degrees:
(ifwel[field,ose}at/long issuffieient) 2L Certittcation: MCI 0
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6 are eweD s ehnanent• or em ra SignatmeofC eUCodtractor Date ' ,
I By s(girbtg tbts.fornq I hereb}e certify thae rbd Ivell(s)•Ivor(rvere,�eonsducfdd G,aeegrdartce
7.istbfss n*pofrtoanexbfingivali. MYes or 13No Ivllhi$A? .fCO2CAlgga;-MdNCRC,O2CA10 WellCow&&WonSfmdgrdsandlbato
ljthlefsarepafrfrftonelarmvnweUeonsoucttonfirformoNonaad.orplolnthenalrrnojthe aalYofthtsrrdoxllratbeenpAovtdedtothervellmarrer.
repaG•trrtde{#2l remarlfaseetion oronthebaekofth[sform. •• ',,' • ;
I 23.Site,diagramor additioaaiwell details:
8.For Gebpra'hdDPT er Closed-Loop Geothemud Wells having the same You-may use the back of".page to provide additional well•site details or welt
construcdpa,oalylGW-lisueeded.lndicateTOTALNUMBBRofwells ���ctioadetaiLa.YoumayalsoattachaddMonalpagesifnccessary.
drilled: � $UBMITTALINSTRIIG'CIONS '
9.Totalwelldepthbelowlandsurface. (,C C• (ft•) 24a.For All Welts:' Submit this form within 30 days of completion of well
Foramlt/plewe(lsJlstalldepthstJ'd{Bennt(rxampld3QT00•aad1Q10a0 eplbIctlontothefollowing: I• •
10.Stati�water level below top of easing•. (fw) •Dlvisfon of WateitResl uices,Informatiou PraceWmg Unit,
tjwaterrevlllfsobovaearra&aim �. �
• "•'i617MailSecvIce,Ceafer,Ralefp�yNC2T6991617.
11:Borehole diameter. 24L For Infectidn.Weliai In addition to sending fife form to the address in 24a
12.we11'oonstructionmetliad: i-e A I. abov%Also submit one:copk of this fad within-30 days,of cozo lUtion•of well
construction to the following: i
rEc.auger mtary cable,dhdpusb,etc.) i
Division of WaterRQsources;Underground Infection ControlProgcai%
FOR V IMR SUPPLY WELLS ONLY: 1636MaUSenice Cmter,Ralelgb,NE 27699=1636:
13a.Yield(gpm) {y 'Method of test:, J.7"4 ?Aa For Water.Supply&Infection Well Ia addition to sending the form to
the address(es) above,also submit.one*copy bf this fd m within 30,days of
13b.DIs' fection type: ' i ' Amount: `� e7 'z S. completion of weU construction to Om county health department of the county
whomccnstructed.
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