GW1--03146_Well Construction - GW1_20230505

WELL CONSTRUCTTON RECORD ffi W-11 For Internet Use Only
1.WelI Contractor Information: r
A :•�, . .. .
Well Contractor Name FROM TO DESCRiPTiON
A % pp
N€Wa0 Contractor CettificattonNuntber
Y O 12' SA4i T tb doe ;.'liir tb R if n�`lii atil ;;;`'::�F "_
Gadj �D� 11-1 L Y 00, FROG TO MA�lfi7ER ]7dI�KVfiSS aVL1TERL1t.
• •Co,npagy erne
tt, it, In. A
000/04
2.Well Constructlon Permit#: dl� FROM To DtR TiutsalEss �T$�y
Liss all applicable wall canstruetion permits(fe,UlC Cow%State,;F.'ftCtice,etc) It. it. in,
3.Well Use(check well use): -:• ' it, fa tn.
Water Supply Well: MO.,
FROM TO D SLOTSM
❑Agricultural O�vlunitipaltPubiic ft. , !t- ' .3n., crttiFss 3t9ATEAIAL '
00eotltermal(Heating/Cooling Supply) . dResidential Water Supply(single) In.
01dustrial/Commmvid OResidentiai Water Supply(shared)
131krioation OWetls>100,000 GPD I aft M I To t r x ' on A.nMOLWT
Non-Water Supply Well:
OlYfo�torIng ORecovery tt: tt.
Iqf eetloa Well:
❑ ifer Recharge �• ft.
�N ge ❑Ciroundwater Remediation
Mquifer Storage and Recovery OftlinityBairier. 'XI9
FRt3�1 TO i MAIERL4L EMPLACGNlEPiTMBTHOD
LC3
st ❑Stormwater Drainage IL IL
;;_; . t' -,
al Technology ❑Subsidence Control % fr.
(Closed Loop) OTracer1611,
eatin Coolie Return 00ther lain under#21 Remarks FROM TO Dtssc ors color bards ,owncit 221,a
4.Date Wen(s)Completed: a y 'd�Well we n. b, 7L
, .
Sa.Well Localion: "� 8. � it. -41
atk
'r4? V- Ll0 71 iU : . E I V'E
Fa cility/Owner i ante FOMW M#(Ifapplteable)
PtrysicalAddress,City,and iL
tt. Ini�rY'sM'^n i'r^G+99r� tu[
Co��L� Parcel Identl8cuton No.(P1N) �
Sb:)Latitude and longitude in degrees/minutes/seconds or dedinai deLrreen!
Clfweft field;one latilong is siOcici t) 22.Certulmium.
N w
6.1s are thewell s: a e t SI a( ) () G�'erm n n or ❑Temporary gnahan Certitiad Well Can atati•
Date
Bysigning fUrform I hereby-cerlo drat the wen(a)war(were)coMhVcted to accordance wryh
7.Is this a repair to an existing well• ❑Yes or Mo 1SA NCAC 02C.0100 or 15A MAC 02C.0200 Well ComoVetton Standards and that a copy
Ifthts is a repair,fill out Anown well constructlon information and earpkaln the nature of the ofthls record has been provided to the well owner.
repair under#27 remarkrsecdon or on the back of thisform.
23.Site diagram or additional well detafls:
4.Cva vwuyco'nerura or Ciesed-Loop'GeothermalWells having the same 'You may use theback of this page to provide additional well conshuetionin%
constructign,only 1 GW-t is needed. Indicate TOTAL NUMBBR of wells ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
dulled. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fk)
For multiply wells Iasi all depths(fdMirew(emmpIL-3©200-and 2®J00 Submit this GW-1 within 30 days of well completion per the following:
10.Statlewaterlevel below top of casing:�o (ft.) 24a. For All Wells: Original form W Division of Water Rcsovrces (DWR),
(fwater level is above casing,use +- Infomtation Proce aing Unit,1617 MSC,Raleigh,NC 27699.1617
1-1.Borehole diameter: (in;) 24b.For Infection Wells:Copy;to DWR.Underarnimt#Tr iierrin„rmtml tsar)
-�- Program,1636 MSC,Raleigh,NC 27699-1636
�1I r
12.Well construction method:e r " oY 7yt• 24c.For Water Supply and Open-Loop Geothermal Return wells:Copy to the
(ie sugar,rotary,cable,direct push,etc.) COUMY env=oln a department 0 the county ere m e
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rtidudn' over 100,000 GPD: to D
13a.Yield(gpm) Method of test: " W Peraut rogram, 11 C, e C 27 9•t 1 SPY 'CCPCUA
L
13b.Disinfection type: Amount:
.
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