HomeMy WebLinkAboutGW1-2023-02135_Well Construction - GW1_20230303 VVTLL+C0119TRUCTION RECORD(QW 1- Por lntem21 Use Only-
1.Well Contractor Informafion:
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Well ContractorName Eton TO . DESCRfMON
IL ( fL
( j NC Well Contractor0=0cationNumber
Ov' i j I_j r JS.OIITERC`I�SFNG(for mal&cased wells)-ORTIMtt n licahle
TROAI I Tu bTkMET6it TSICIQIE55 MATERIAL
Company Name 1h 1 6 in. ! ( e—
M-
���Q�g� I& MRCLLSQJGORTt7EING eothermalclosed-lna )
I 2.Well Construction Permit#: (JJ --LL FRO-Ad za nrsnrET� Talelarass MA7TRTdT
f !*stallappGcahleTvdflcomlructionpermitsCe.UIC CO- ,Struts Variance,eta) ft I ft in.
3.Well Use(cheekwell use): ft. in
Water Supply Well: 17,SCREEN
[)Agricultural E14xs _ bROM TO DYAML•TEit S_0TS= 3B M4ESs MAT'ER
F.l'i"xtmi b1tC ft; fL
Geothermal(Heating/Cooling Supply) tdentiai water Sn I sm he
Supply( g ) ft { ire
IBdustriah/Cornmercial , Residential Water Supply(shared) -
i ; 18.GROUT
I Irtigatiou FROK ITD', MATERIAL EMPLA MMEK-r1VtE 11D&AM
{ Mon--Water Supply Well: U & U
4Ij -Monitoring �Reeuvery (L fr.
Nection Well:
Aft.ft I ft
9 Recgehar 13GroundwaterRemediaaon
I s9 SANDIGRAV.ELPACKCrfa -IFcaldc
Aquifer Storage and Recovery E2Salinity Barrier MOM To MAMMAL
' Aquifer Test OStormwatuDtainage L�airracEAisrtrnEETxor
i ExpeiimenWTecbnalogy nSubsidace Control I ff
j }� Geothermal(ClosedLoop) DT=cr 2tl.DRIT,LIl+iCyOG(attachadditronalsheetsffnecessary
-Geothermal(Heating/CoormgRetum) _ Other(explainunderAZIRerawks) I strong TO, BFSCRu�rIOK(cotor,l�caacss sotumac "�,tn
a ft. ft. G {
4.33ateWell(s)Completed: 1` 7 0 2Z weu
Sa.WeIIJL bolt: Cfft L7dvfT: 6-PA- �
Facility/OwnarName Facie � ft
(ifappficable)
Pr ft I fi: . T„
j PhW1cal Address,Cit}; 7iP u,.Q.....-
I
Count` " t PatcelIdentiiicatioa;`Io.(PIN) J
{I1i7757 it 77- 77,j t n;i
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(1fTvc11 field,�A6�attloug issu€5cient) 22.Ceriificatio
W
I 6.Is(are)the velh(s) ermanent or QlTamporary Signature ofCenified.Well r Date
i By signing This tri r I hereby certif}r dwc the nwa(s)Tvas(svere)•constructed rn fire
f I 7_Isthis s repair to an existing Well: G€es or, ego tivilli 15tENC�Fe d2C.0100 or 75A NCIC 02C.0200 WPJI Constnrclion Standards or.
1J'!his.isareoai,fdloutkitawrttivellconslrneliorzlnformaliooande;glainrltenatareoJif �pP�� has beertprovidedtothe:ve_ltolmar.
i repair under*2I remarks section or on dte back ofthisfarm.
23.Site diagra or additional well details:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use tie'back of this page to provide additional well site details
construction,only 1 Cr -1 is needed. Indicate TOTAL NUM8ER ofweils construction.de .You,may also attach:additional pages ifnecessary-
ddlled:
j SiJSMlT1'AI. STRUCTEONS
9-Total well depth below land surface: 24a.For All Wells: Submit this form within.30 days of completion
Formaltiple�vells3fsraildepthsifd�erent(eromple-3@200'and2QI003 co �on.o he following:ji -
IQ.Sistie water level below top ofcasing: Division ofWaterResources,WormationProcessingllnit,
"Ifivarer level is above easing,use" "
1&7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in) 24b.For In9ediBn Wells: In addition to sending the form-to the address
j .I2-Wellconstructionmethod: ��0 ro,�'-Lrk �°°% O -°�copy of ft form within 34 days of completion
conshuctionto eforrowin
auger.Waxy.cable,duectpusl> eta) I i �
FOR WATER SUPPLY WELLS COYLY
Division of WaterResourees,ilndergroundNection Control Progr
1 361VM Service Center,Raleigh,NC 27699 1636
t, I
j 13a.tYleld(gpm) 191 Method of test: �v� � 24tn For Water Sun&&Iniectiou Wells: In addition to sending the:
j I �1 AJ the address(as)Iaabo% also submit one copy of this form ed kk 3D c
13b.i3isinfeetion type: C'fi� Amoanf: _l cornplefion of 11 construction to the county health.department of the
4 where coushuc '
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