GW1--05957_Well Construction - GW1_20241009

. .1 . . •. • .. .WELL CONSTRUCTIONLRECORD (GW-1) ; For 1111071E1 Use Oaly: •
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, I.Wen Conesetor InfOnuation:., . •
• Russell Taylor .
1..WATERZONES •
Wen ConosnorNson . . • ' 5730SI I' TO I DESCRIFEKIN
2187-A 1 151 'I i I 02'
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SIC Wail Coon=:-.-of....e..-Naga= .
• • Ii 4164,2ftilAA ft- 1 -
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! MOUSER CASING mar aston..erost yew 031z1143:110r• 'Koc:len Brothers Well PrillIng,!no - . ! FROM• •1 I TO - I DIVETER TRIC3041310 KOWA
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• , Connonyllonte
. . ( Id.BINERCASING OR MK=fueotheemal elneuipl000l •
, • ' L Wall cos Permit#:. 0503.94-1 . 1 ;sou "LTC i,DIAMETER l MEMOS . =MI&
. , . Lin en appitelbir Ma ettnInnetton perstfts az WC Comaty,Stat4liitiarse.etc.) l' 0 ft
1'40 ft. 1 IP 172. 1 PV6"3.Well Ilse(duck wen use); • 1 10 "TIM '41 ip, '". I .1138 Sres
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..Winer SIIppip.'Wen: 1.7.SCRED
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. • - - „_ • ' FROM I TO I DIAMETER SLOTS= TRitnibolS1 ' Az,
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Agaieolstral ' . LIMunieipal/Publie ' it 1 ; ft. I
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Geothorrool Ciimainfie.earzog Supply) 5)Residentia' I Watc Sizpply CS111810 I . • ft..1, -
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IsidinC =aia Cratcsii=e2c1WatSuPPIYtsharod) .i 1L GROUT . ...,. I
brim:ion - ! Ross ! TO MATORDS. I 7OUlt.ACIITEMTMETWOO 11
Non-Water Supply Wen: '
I 14_ 0. f.- I 20 11. cams i es..- i Crtageited
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. inaeocrvety - ' '
ashen.Well; .' • 1 ft. I b:- i
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"' tees Redasge ' OCITOrsachifox:Kcperagtivz i
Wit -• • i 19..SiMICIRAVEL PACK tir rl ma :ebb)
, • SIZ7Tage and Itaxavay , uSalillityBazi= ,PROM' : I TO I UTERTJI. • 1 1?"14'..".1,Tr'SV
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. Telt. , . Otis:nova=Drat:ego . " 1 ft.,I' ft. .,„, .
Expethaeosel?ethnology DSobsidenze Control 1 I 'fr.,.1 , - it. ' i .. .
, • denten:nal(Closed Loop) Onto= i' 20.DRILIMG LOG finsach additiond sheets if neeessar0
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osscourrtos Wen tonlatnaeneeektemageti
Glicikennai ategtinoccoliagRecuco nom=(=wain Cad=al-Reraitks) I PROM ;'. TO
- 0 ''''il ast day a ma
• ., • 4.Data%Ws)Carapleced: q 02.1/410. 4 , Alieli I:Dti i.,12., fti boo 11- c.a.
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. . 52.Well Location: ' • - ; •
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PCIGIn 4 Jes&o.rncevotoi+z.. .
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FeaDity/OwnerNseke • ., Tocolity rad CifainGeebie) ! ' fC' ' % - ' g ‘‘';''''' '•'`''•tv.--'',I• V .;••••. *4 )! ..
4441U . 464,Ste..0ife, Ra 114 irikliVii 4817 41 • . OCT. 0 V '2024 -.
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?bites!Address.City.ond Zip 0
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nem, Cati.771, . •
/45(irtiPS 880. i 21.1012243.1.3 I ry7:17'7,:tr;',--, 7)-- .
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DIPC.C.6•;17..*
Caii=i • . ?creel ideatiffgad=No.(MO :
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. Els.Lents:do and longirtode.in degreesinaboutesiseeoado or deoftnal degrees. '
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' .Owen hid.ore Wong is sofficicsa) • IL Certineation:
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068e Oq• )68 W jeorj6149,2...gp cuz"..larin... ..
toi.ktri
ofC&-dfial wen CCM=• 5.Is(ere)the weli(sytker mum= or Temporary •Signature
• 3;5;31711W It*ji 17a.I'hereby or*that sreil(s1 sass Nem)onotratord A
7.Is thin a repair to an existing wen: 0YeS or pivo • „tiimzicir 02C.0100 cr ISel=IC 03C MOO ad Constrarrist Assign
Ira*It a remit:Jiff art Moon mil esatiraccian iteirrnivion Jrzplcii:ae aczeo=apar coPY grab'7crihcar becr:Fravideiro the wiloorzt . ,
repair tzar ACI matrix=dart or es the&coke*Om .
' . 13.Site diagram or additonal well dealt: - ... .
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You ditional vtll site
may use foe beck provide ade du
$.For GeoprobeipPr or Closed-Loop Geothermal Was novice the=se• of this page to
construction&mils.You may also attach additional peps if neoessiii,
esomnoetiort,onlyi GVA.I is needed. Intncate TOTAL MUM of wells
• Wiled:
. sUSUrstTAL mrs-rAueirrom•
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• 9.Toted wen&mitt helm Lund:tufa= boo ( 1,43.For.Alf Wells: Sub=lt-.115 forms within 30 days of comp*
For stalttple we&a r tall depths rellfferent tiemenitip.stigoo•cnd 2tgtf Sal
woo-somion to to f011owiom ,
• I 10.Sods water level below top of casing: g 0 (ft.) . [Di-vision of Water Resources,Information Processing Doi
timer levet ir rthava cataz use--.-- ' !' ' t617 Man Svvica Center,Raleigh,NC 2769946t,
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11.Borenole etuasortr: Lip - For It:ejection wens:. In addition to Mtge&the fethe to the aili
' - above,also sto.ft cyc copy or tato fano Ilitalai 30&ye of maples
. 12.Well constructio' ti method;
alit• /Liar. - . consraeziO ea te followins
CUL=BM MX'S cable.tfireet posit.ere.) .,
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, . Division of Water Resumed,Undergr000d Injection Control P
• . FOR WATER SUPpLY WELLS'ObtLy: •
I t , 1636 Mail Service Center,Raleigh,NC maser •
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• ' 13e.Yield(gpin) )0 Method of cesc Erte63 24,z.170,J1.;orer Suptav At Infection Wean TA adtrition to sending
; the edoross(es) above. also sobtnit one copy of this fon=within
' Mt.Dis'bawd°a ry,p t.Ss •I i A ....4..mottne: • • I re O'A.1.,,, corapiedip or well=swan=•to the ostany health deponent=ni
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i,. ... • were Go:truce:mi.
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" . ..,..perm OW4•1 ?..iQr .CarYtor.Dwz1-...scr.ofEr.;-zoorz.ovs:Quzlity.D!vLsion orWago-B..corys Uri]
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