HomeMy WebLinkAboutGW1--00784_Well Construction - GW1_20240131 1
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I. PrIntFonn
WELL CONSTRUCTION.RECORD.(GW4) For Internal ilse•Only:
1.WeII Contominr Iiifbrmationt I '
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DaAd 26!Cher
'14.WATER ZONES- 1 I • '
Witi ContraotorNtans FROM TO DEICRIPIION I
4594-A ' lqo IL ica ft' 5'ND it Miejure) , •
ft. ft:
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=Weil ContnusarCeoffication Numbs;
IL OUTER CASING(for remid wells. )
Aqua DriP,Inc. LINER Of micohlet ..
Inc. 'PROD TO nmis
S' irrnit' IRMO= MATERIAL Company Name O L 8 0 it. 6.Z !ris cepiLli. ' . Pvc
16.DISERDMING°RIMING Iteatit. eitted4esel pa .
L Wdi Comdractioin Permit#:n-lbiPa 316-CCJ 5 ea.OM sw
Lista!kupftesble waft canursiesu malts As.IJIC,Counc4 Stitt Varkaus,etc.)
3.Well Use(sheeting Me):
'Water Supply Well: 17.SCREEN
PitoLt. _-TO MATURIAt.
mum= WTI= THICTIMISR
si III dgriculhaal • Dya*ipaUPublio ft. .ft; it
lit Geothermal(Reding/Cooling Supply) -Mite:Wadi Water Suppiy(single) • ft, - te.•
1 Inditstrial/Commereist [3gerldential Water Supply(shared) , •19.mow ' _ . .
- •Notion
FROM -To titAITAML., . .IMPIAGGIaNrifinrnoll&AMOUNT NOMVator Supply Weill '
0 ft' .E7g'ft. qprar.mt4e 9euir C 11'ir,R 4 Htir)irtio
a Monitoring. ['Restively • 'ft. R.
'election:Well:
MI Again'Recline DIGnamdwater&mediation ,
IL SAND/GRAVEL PACK(if analleshle)
01,Apilio StMage and Recovery DElalitiity adder FROM TO " MAMMAL - ammAcannna mamma
11, •. i', Test II3Stormwster Drainage ft. it.
•11.Experimental Technology Dilubsidenco Control • ft. - ft. ' I
,
tif.Geotbransi(Closed Loop) DM=. 20.DRILLER;LoG Wait'Maw emits Wanossors0 -•'' .
.ii t.,„,:,„• areatinamoolins Botta) r3other onagainunder on Romado nom _ -To _ DEMPTPUONOrdsA lanlassokfilks ek dna wok dza etAT
ft...• • (DIV c-ildri! Se1 a 4.Date WelieS Completed: I'i7../14 Well 1110 - s • 5 .L ' _Ab IL , iL, 6t-dr;:40.
Sa.Well Louth= a. A5 a
clrAme,r4 WOmes,A'mpn a.
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_. ___„•,
ihollity/Owner NI= irmilitylD0(Step:able) ft. ft. , ("• i" '''‘ ''i-—...% •f T—::,T..)
ft. It.
Wni C.Ohlio f Adi Silinoo;liPi Ale. glotics'
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Phystad Addrcm,CIty,and Zip . fl. IL • • • J A 11 11 1 2024
9,,nevi:rlynnin . '794100.177(15 la _ "j4gmAnn. Ini-i.;i-w-Gz:;;;F.m :. 2-9 Uiri
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County Patel Identification No.(PIN) •
D'.`„%:,',"•112-G '
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. R.Latitude and longittido in degneerIminutatiscconds or decimal degteem
'avail field,one bank sufficlen0
22.Certification: . ' • i
c a7' q9.94 N 740 fig' Li 9.,9' . 117 (Ail . ' l'ig•;4 .
.Kars)the we11(1)631PS17021lent or D'ftmporary S = oignf Certified Well Contractor Date
By skidag Mb fora I hereby we that AS ws11)was(ltww)constructed In amnia=
7..h Ude strop*to an martin wells DYee or "Iti'a • i with ISA NCAC WC.0I00 as ISA NCAC OW.0,128 Well CoasbuctIon Sissdards and ilk,a
if othiskaogpainiumwato.fiamnnesiontionnatonanderpkdatkenahreofth. coppethinvonrmaiheaumukreatothenvi ivm •
repsdrisider RI mash stilton or an Me back eats firm. i'
21 Site diagram or additional well dehdim
B.FOr•Gernwobe/DFT or Chwed-Loop Geothermid Wells having the same You may tItelh°lliWk of this Page to Putrid°additional Well eltedeleilier welL.
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combustion,only 1 13W-I is needed. Indicate TOTAL NOMEIffkof wolfs mantruction&tells: You May alai intuit additional puss if nomattary.-- ---.--
..:drilled:
•fasit3SMKTIMILINSTRIICITONS I , •
D.Taking depth Wow land surfaces gi44 . 60 24s.Nor All Welk Submit this form'within 30 days of completion of well
As mulftle wells Wail depths farm ftasesple-41200'canna') constioctIon to the folk:wing: i :
10.Stith wain led below top Of adopt - 140 • (ft.)Patsy live DIvidon Of W,Mer itcsourcesjitaformadon Prommingraft,
n s above casIn f g in u+"
16171ffidl Service Center,Raleigh,plc 27699-1617 • .
IL Hostliole diameter: ft, (it) 24b.For Mutton Was: In addition to sending the form to the address In 24a
• above,also submit.one copy of this fain Within 30 days of completion of well'
12.Weil construction method: tkikrzl_air construction to the fhliewinx OA=Ewa Mel%sable;direst pusb,am)
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Division of Water Resources,lindergimmd ligation Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 ASO Service Centei,Mkt%NC 276914636 .-
i 13a.Yield(ppm) 5 .,Method of bah alicb±lme..._ 24c.For Water SODDY&Is ildection Wens: In addition to sending the'fbim to.
the eddresdas) dim'also"submit onri copy of this than within 30.days of
13b.Dishdeedon typos.WriAsie;)% Amount: iiiipz. . completion of-Well construction to the'county health department M the county
Where cOnstractet.
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Font GUM NiutheratinangutmentinnvironmentalQuility-DiviskinteWeiteritesources i ' Ilitufairl 7..”..91114
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