GW1--03964_Well Construction - GW1_20230612

WELL CONSTRUCTION RECORD (GW-1) ForIntemal Use Only. ZZI
I.Well Coarmctur Information:
Russell Taylor , 14.WATEBZONES
Wen Conna=Na= FROhr `` TO I DESCIUMQN
2187-A
!IC Well cmmwar Cert[ECtdoa Number
I fL
, L3.OtTlERCASIISG multteasedwdls 08LIIVElt
Madden Brothers Well DdIring, Inc I FROM I To TMOCMS bkMTi1WL
Company Name
I I&INNER CASING OR Tt1811t'G(nothcanal el4ted
L Well COMMCdOn Permit: aDaS-J464`7- 9-' I.Z9[,p i FRosr TO nruatEtER Tsrcrcv�s MtATtRWL
Un di appikdIe-it cv=nt MGon paarru(c.e I71G County,State;Yatdenee,etc) R ln.
3.WOU Un(check wa me): % [oim 1 1.48 TEE L ,
[AquifaTest
ppiy Wen: 17.SCREEN
FROMi TO DIA.1tEm Mars ZE TfOCrp1fF55 MtATERfAL
E3Municipa)1Pablic ft fr. in.
i
(H-Iing/Coaliag Supply) MResideatW Wata Supply(single) ft. ft im I
aUCoInguce I OResideatial Water Supply(shared) I&GROL7T
brimation FROM TO I Nr►;EFur. I LNsrtaCM, 11 MEraoa s A3ro
rSupplywelb ft I ap ft. I �._,�.� Otanoed
ring DReeovery i m ft
ell:
Rcchatgc E2Cnnuadw&=RcmcdizdQnSronge and Reco 19.SAND/GRAVELPACKff Iel�Y Saliniry Barrier MA i to sTt:RrwLT� MSto=waterDrainageental Technology Subsidence Controlmal(Closed Lo
ap) FDRlLL1:-GLOG nuacbaddidonalsheetsifn
FROIaESCRIMMNlooter.hardamsoMN"Tt.MIDsuLetGlrmal Mcatin Colin Rattan) M09=(explain under 21 Rama=) O I tL I clay a sand
4.Date WcU(s)CQmpleced: 3 well ID;= ra
6a.Wall Location: i
90o, mO LLC
I i
1 � ,
°adliq/Owaa Vaple Facitiry IDd(r.-applieablei ff: I ft.
�W QJM 1^nreA- Tai 1 I�ulln_ �..ka�7 .�87ir.'s ItlfOfr'13�'i;;1 PrccR22i. !J z.
mysfeal Addnem City:and Zip
.5 I e"ael Ca 03::y 7 5 43—35- 10.41
cdvnry Parcel Idcndfieseoc No.(P Dept W LU —So-f+t Secant,J�T145
5b.Latitude and longitude in degrees/ralautes/seconds or decimal degrees:
(if WCQ field,ene 12149ag is suflleleat) SL Certification:
35' 08-939 .r 08�3° 08 .412 w 5
6.Is(are)the vreil(s) Permaneat or OTemporary Sig=E=ofCatifiedNvcllCon==.
dl sgrrirg:i isJornr !irereer arrify teat ite11�SI��(SlYR)caaattacied in aeeardm
7.Is this a repair to as esistiag welt: [3Yes or No tv W1 JIM:rCAC 0ZC.0100 or 15.4 NCRC OZC.0200 kill Caaarredoa Smrdardr and lla
Yfh&It a repair,fdl out lmot.tr ivrll eaestrueriaa tafarmatioa'PKplaih ree r ",=of tier cope Creels rresrd itas been provided ro rF.e r.Ytl aLxer.
repair raider#271 remar a$nation or as the back offlur fame.
a.Site diagram or additional Well details:
S.For Geoprobe/DPT or Closed Loop Geothermal Wells having the same You may use the back of this page to provide additional Well site details or a
stra conctic0. G only I W-I is needed. Indicate TOTAL NI TUMBER of ells consuuccon details. You may also attach additional pages if necessary.
drilled: I SUB M.- lTTAI lNSTRUCTIQNS
9.Total well depth below land surface: I Et) (ft.) rqa Fer -Am A ells: Subrait this fo.-et within 30 days of completion of v
For muldpleuvl&rat all depdaifdorererrlCe=o7k-3QZ00-=d2 1001 consmuctionto the following:
10.Static water level below top of casing: (tit.) Division ofl'rater Resources,Information Processing Unit,
lftmurlawl it above easing,tar'•=- 1617 Mall Service Center,Raleigh,VC 17699-1617
11.Borehole dla nmr. L a (La.) 34b.For Wection li'eiisa In addition to sending the form m the address in
Lit 1 IU�C above,also so the following:
one copy of this farces s�id+in SO drys of eemplaaon aF t
IL Well construction method; wnstnreSaa to the
C—auger,rotary,ablc,rinser push.etc) �--�
Division of water Resources,Underground Iijectlon Control Program
FOR WATER SUPPLY WELLS MNLY: 1636 Mail Service Center,Raleigh.VC 2709-1636
13a.Yield(PM) O Niethad of test GYM itA.J 7rrc.For��, er Suaal_v_8 Infection�4elr� In additionto SeadlLg the fart
;ire addresses) above, also submit one copy of this form Within 34 dry
136.Disinfection type. �t � amount: � compic3on o:wall cansauction to the county health departateat of the CO-
where constmc=d.
Form ONNI-i ONt Caroiml DC7aRTLSit Of T�TO�T:nI 1 Q<i:�'•�I"•'SlOr.O'.�:_.v`r Rr�CfLC� ItSl7ttd -��-