GW1--00990_Well Construction - GW1_20240209

WELL CONSTRIJCTION:RECORD(GW--gb ' Farb.temalUs?only:- - •
Print Forrit'
I.Well CoithadorinliismnBon:
David'L. Hardy; Je: . -
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Well COmmeMiNeme• • .FROM-: . 'ro : : .: .DFScrapriONi. ,. . . ,
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NC Well Cieuiaam•Cistifeiation Number R
1,,a�� .Diu+'�t. ��C. UTCR CASING(fosmp ORIANER(Ifeeulteeble) -
�• .I-INNER CASING OR TVDIN°(� demed$oop
• " '. '2.Well Constenedonpermit# =• : .troa • 2» • ' •D , •
MUCHNESS I& w• ' Car ail applicable well eanstrreianpermltr allIC Comny:3mtemana:ce) 'IL �•
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. 3.Well Ike(checkwell.use)r. . • . ft... : • . •ft.: : : : ta, . -
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Water Supply Welk. •
: 17.SCRt3r3w "
cultural' ��qq'����� . 'MOM'.• ' D DIAMETER suing= : THI NAM:MAL
p:,yid crpaYpablrC •Geothermal.(Heating/Coolfng Sunlit). •' Resideatit of WaterS .. �" _ 'R. IL- is
industnei(cotlimen;iai: •DResidtintialWatcrSupplyC�rm,rd):
:Irrigation: . . . a0:GROUT. --
• FROM • TO Rrernnrnr.. • .EetPI.ACulVQNTP eD&AMODNI.
. .Non•Water Supply Welk:
iN!Monitoring t+� •
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1rAiectionBitW: Rtxovery,
hiAquifer eobelge : . .
•?'Sn imdwaserRem aliation. - •: -
tinifbr5torageandRecevery •�$alimlyBamier 19.SANDEGRAOBL PACK Ofemilimble)-.' '. • . , .
PROM : .TO " •1AquifcrTest . . ' ' Staimwater. ltlAamrrAl. sa ,►emsmvat�tsoD
enlalTechnology SubsideneeCoatrol '
;y. ;",,,o1(Ctosed Loop): i '
• r• I `"" - . •.20.•DRILLINaLOG(antdnaddltionel tf i e ssarr). -- •Geothtuntel(Heatirt�/CoolingRetttnt)'. ' Otirv(mq:laiaander 21Remarke) PR°nt. 30. D mmro
a. " ..'''t, : 1, i-9" �'• . • .
Se.Well Loeafton:
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F yro<uurNome fie jm (If0ppitmbte)' ' lt: fL "'";
�Add,eta.citl;uadzip. (.. . .
7 S/� zl:�esn�aRlss. & Efj �1.' ;1UZ4 •
in •x •
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Ceu Pmselide fiea>ioa]Vo(Rll�' • ttlfce mane.I er.c umawl-2 Urti.
SIN Latltndeand longitude ta ' .. 11tC.'w3C .
d,' eslraintttssfaee4nds or decimal d
CtEwellftel4weletltaegil=Mi i)•. -
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..0.17‘.$717-ti• • ..-.•:ri. la.. 0- '2./044* ... . • • -14 •. 7:
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6 IS(are)thewdl(el ont�t'.or sl•.r...ofCert7SedW �" � ���/
7.Is this a it to,an existing - By arguing l kan llar e5yem.,(6,din.the.liedff(ig irdr firm natt�rn aaaordonee • -
d7 Let hb gwell,: ®Yes'•or No• .wigISANCACOIC.0100or15A NOW 02C.02OOWedlCoa nzglos and tlite,:
repair,.Montlutatwellc end ycnairderplQOlihsngpvciJm - - wAviet amilmsbemtpmvtded,11"vrllenmrp:
tepatttmder021 repailandlon
:Z:Site diagram oradattionel wait itetauer EliFor Geoprobe1DPTorQosWIaoPGeMbenin lWelltzhavin�thesnnie Y;._.*:use.the,backofthispagetoPmvideaddig nai7411itedetat7s'erwell
• - consluc� lion.only 1 OW-1 is needed;-Indicate T YAI;MJMJBERafwees - en fiction delaps.You iH.,.else attacheddifitmal pa :ifnec wy.
•• - • • S[1BivarrAL tranittor10NS • ,
9 Totolwdl depth bdor+.dead sutfetac �d •O
• . 'FaraudNpleudLrltstaUdrpth,rjd(�emtt(ermaplo-3la0200'aad2 10 :24a Par All Wdla:Submit this form•'rl hin'30- '
. ® 0'J coastiactiontothefollowing of Cornpletimt'of.Mail
I0.Statfc�iatertevehlidpiytopof
.Iftrmetleveitaabdva Wed+^.. . . ( ) MikanofWetia Resottrep,IafoimmionPrat sUnit,. ..
/ .1617 Nail Sekialee.Ce tes Ra NC2765946U 21.Borehole di»eier: •A . Om) * . . ' .
n • :241i•Por_ioiecNan einsi In addition to*ding the form to the addtma in 211a
jive]]it) ' • '• fiimt • ;.•••. /;;%' 7/ T above,alsosubsoil:mlo:Apyofti»s.flme'ww �18 completion.ofwell
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ao•a smewombla:di,eerrml.1m.) �: L •. • - '.eoa5hnctiontothefouowiag i
• FOR WATERSOPPLY WELLS ONLYe . •'•Division lvtst otWater n See rues,tW ibir,aleJ p,rqC lea Control Srogeatit,
r /.,/ 1636 Nan stwvieo Center, I11nl�et�h.Nea76s9�;163s: " •
:13a:Yield(gptnp. - (E •blotoftesh 7 r `l./ . 24tr Water Sumlv•R Wteo61en1Veils I'Inaddtioato sending thefbim•to .�.' •t e iddross(es)above,also submit one
13b:;1DisintNcQon;type • :Amonntt . SPY he this faun wi0titt 30 days of:
;completion of well t:onstrirttion to tiie'coiatty health dapal4n®t.of the County
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.. %hereconstructed.
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