GW1--03963_Well Construction - GW1_20230612

W :-- •'P.riRt:i
ELL CONSTRUCTION RECORD (GW-Il For Inremal Use'OnIy:
i
1.Well Contactor Information:
Russefl Taylor 14.WATERZCNES
I FROM I TO I I 1 DESCRIPI40N
Well ConasciarNs=
2'167-A !
XC Well Cana&=CatMci&o.Nataber I 15,Q7p CASII+IG or maltt ested wells ORLIl�iEIt
Hadden Brothers Well Drilling, 1nG 1 FRONT TO Dsu►iErER Txiatvrss iusstwa
tt: fr tn.
Company Name 116.LYNER CASING OR TUM--G closed
L Well Construction Permit .4Q3/-9— 1.6n 1 FROM I TO i Dsa..tE= I TBICXN s MATMUL
LW all appitrable trait ratrrnalan permit:(i.a,UIC,Cowtty,State Variance,ar.) I tL 138 R /„ In.
3.Wen Use(check wen use); 1..3a M 1 40 � u� 1
� o
ICMWxmal
tpply WW L- 17.SCREE:C
FRoai 1 Ta DrnatErER siarstzs slact�ss M1iTz;RUL
MmI •)MtmiicipaYFublic ft. ft. ia.
ermal(Hearin&/Cooling Supply) MResdential Water Supply(single) ft. ft,
aiaVCttmamrcial Residential Water Supply(shared) IL GROUT
ion e'RO�f TO I MA.IERLtL I n1PLAMt11TdEEfHODi,l�i0
ater Supply FVefI: it. I m - I �.rc ram 'toring ORccovery ;I tr tt- 1
n Yell:mrRcehargc DcmoundwatcrRcm19.SAND/GRAVEL PACK if Irsable)
Storage and Reeovcty M-Sailaity Barrier FROM TDerTest M-SW=WatcrDraiaagc I tt. Iimetu l Technology Subsidence Control I fr. I t£ermal(Closed Loop) M.Tmccr 20.DR=N.GLOG aMeiraddrdoaatsheetsif
FROMTo IDESCFtIermal(Hratin olio R'ea,, )), Other(explain undo=21 Remad-s) I—O I 30 I clay F.sand
4.Date Wells)Completed:y51�boon ES`eil M I ft: I
—
Sa.Well Location:
M.Q6.L Ne I fM I fL
i
FMMty/0W=-,4=ac raeiliry IDS(ii apptieabiei { fL I fti I .
4ri7.'%+ern AII2d syova o�8r179 . ._ — M
1 ft. i fL f te, nR ..
Physical Address.City.and Zip /f4 U 8�1 a �L RiFlflil3 +
J taC iLSoNI Ce.taT�1 /5a -6907 21-REM4.RIC4 County Parcel Idcadficadon\ 1 o.En u,rr pc1gm Lbuw
Sb.Latitade and Ioagitnde in degrees/miautesiseconds or decitaal degrees:
(ifwca Sou one tat/long is sufficient) 22.Certifr:cation:
3 ° 19.o?I2 N 083° 1 b. !o? W
6.Ware)theweli(s) Permanent or OTemporar}' si�turc ofCctificd�vet[coaaaCtor
3y-s.'gnirg:it's fornr,1 herrgr certify rhal r ttr,7(r/ Orem)cmvmcfed in amnh
7.Is this a repair to an misting well: C2Yes orP.I=Plair
ND ;+stir!Sd rGIC 03C.0100 ar 1S.4,VCAC 02C.0200 Well Corrnaetlw+Sandmds endd
lt/tir Et a repair fell oat krsoua mlI ewrsaatrdiors irsfarm¢:iars the rerun;q;the %3'arid;rr=rd irar beer proWdrd to the+cell ouaer.
repair wrdfr 921 Mmarkrj=oa or err rre baal-ofrlurform. 23.Site diagram or 3dditioasl well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal WeIIs having the s�aie :ou may use the back of this page to provide additional Well site details or'
eonsnction,only I GW--I is needed- Indicate TOTAL\VNIBER of wells co�m'�0a details. You Winn also attach additional gages if necessary.
drilled: I SUBMITTAL INSTRUCTIQ•S
9.Total mil depth below land surface. 700 (ft-) Z4a. Fnr .411 Wells: Submit this fotat.vithfa 30 da}3 of completion of
For multipir uTtIr Irtt all depthr ifditferml(esaarplr-3Q¢200'arrd 1Q/001 construction to the following:
10.Static water keel below top of casing: 100 %ft.) Derision of Nvater Resource;,Information Processing Unit, ..
lfwattrlevr!frabowearcrZ are'=" 161-1 Mail Service Center,Raleth,TIC 2769961617
11.Borehole diameter: (ra.) 14b.For Iaiection Weil s: In addition to sending the form m the addrts h
�� jL. above,r also to the
Otte rogy of this form r9thirs 30 days of eomplatiott of
SZ.Weil coastrncIIori method: h 1�t1 1 rons�txuctiaa to tha following:
CU.ate,rotary,cable,direct ptuis etc)
Division of'waterResources,Undergrnund IDjeetiva Contra Ptvgrat
FOR WATER SUPPLY WELLS ONLY: 1636 Mail sery ice Center,Ralefgb,NC 27699-3,06
132.Yldd fgpm} 112 Nlethcd of test: d,ii"uw 3+c For Wate:Suaolr Z.Inieetion Wells: 1n addition to sending thQ f0
rrSS I the address(es) above.'also submit one copy of this faun within 30 di
Lab.Disinfection taper T1 3monnt 1 I Completion of l const:trctfon to the county health department of tbe_c
.veil
Waere aonstrucMd.
Form G1tir-1 VoRlt Carolina Depar-cnLog:..,i:on s�;z Q=iia_Di=s or.o:V:s:.rR�oac RLtised2-?