GW1-2021-00720_Well Construction - GW1_20210322

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
. 1.`W��eA,ll Contractor Information:
7
V f'tM l�� J �, �,; �Sb� 14.WATER ONES
Well Cootroctor Nartm fROat TO DFSCRIP[IOIN
FL R.
Npq(,- aq04 R. n.
IIYC WCI{{I1Con/tractor Certification 1Num�b�e1lr 15.011TFRCASING(formultiosiedwells)OR LAVERlif We)
l.t`)� Il"5n11 tJ.R� 'rUlU;z; lf� �a ynl.r moil I TO DIAMEI'tR TRLCKNESs I 1uTFRIAL
n. Leg tit. Ss `
Company Name / I&INNER CASING OR TUBING( dosed-1 )
2.Well Construction Permit#:V YW9t -�•VCP(O S Motif m utAna-tEtt Tmcrw� NuTeRLtL
List a0 applicable well rnnstrarniot pemnts(i.e.UIC,Craton Slate.Varriaim etc.) a R to
3.Well Use(check well use): R. R. in
Water Supply Well: 17.SCREEN
FILM[ I To DIAhRTER SLOTSUE I T®Ch-MESS h41TER1AL
:]Agricultural DMunicipamblic D- n. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R 11. In.
me IndustrialiComcial !!!DResidential Water Supply(shared) IS.GROUT
litigation FROM TO NIA E Eill-AL IEVfMMOD&Astor
Non-Water Supply Well: C) ft. 'JibI R-
:)Monitoring ORecovery ft. R
Injection Well: R R
Aquifer Recharge Q m Groundwater Reediation
D/G 19.SANRAVEL_ PACK(if bk)
Aquifer Storage and Recovery Salinity Barrier Must TD auTERL\L EAIPI.ACFd1ENTME HOD
Aquifer Test OStotmwater Drainage
Experimental Technology QSubsidence Control R. R
Geothermal(Closed Imp) QTmcer 20.DRU.I.ING LOG(attach additional sheets B )
Geothermal(Heatino Cooling Return) Other(ezlain under#21 Remarks) most To DFSCalPrlONlrgbr,l,.taaon,suY.sd -g�,r,o)
tp
d n. r IL4.Date Well(s)Completed:,'Q U 4 a1 Well tDAA12a26bbniG0 Lpft. ft. _
5a.Well Location:
Y10,21 R. RINN
Facility/O"w�rNm M re Facility B (ifapplsm6k) R' R.
,�V`l�fcl���C-t n. n. ,`, c� ,•
Plimetttll Address.City.anpd Zip �( (]/�q /_�-('� R. R.
01, rnKee q 46gw3g9659L1M 21.REMARKS
Conno• Parcel identification No.(PIN) MAn on
5b.Latitude and longitude in degreeslminuteslseconds or decimal degrees.
(if well field.one Iavlone is sufficient) 22.Certification: �� Q —^ ,
pt��"f N W �1�U ,x r
6.Is(are)the well(s)mPenaanent or QTemporare Si uw of Certified Well Contractor
D.I.
��h"" Tito-
this foot.1 berebr mrtifr rMr the weBfsl u'as(orre)cot n atiad in arcnrdmtrr
7.Is this a repair to an existing WeB: ©Yes o[ No h 15A NCAC 02C-0100 or I5A NCAC 02C-0200 Nell Consrraction Sa alards and that a
If this is a repain fill can knaun me0 mtuvrnnfon infnnnntiat nit JcTliiar the nantre of die cap)of rife record has been provided to die nett oawer,
repair under#21 remarks secaroo or an the Lark of this form.
23.Site diagram Or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Welts having the same You may use the back of this page to provide additional Well site details or well
construction.only 1 GW-I is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: OLD (ft) 24a• For All Wells: Submit this form within 30 days of completion of well
For ntuhiple yells fin all depths ifdifferaa(esanrple-3@200'and 2 tr.100')
construction to the following:
10.Static water level below top
of casing: IN Division of Water Resources,Information Processing Unit,
Ifuraer Iar1 o above rasing.the-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24h.For Infection Wells: In addition to sending the form to the address in 24a
Ie
above. also submit one copy of this form within 30 days of completion of well
12.Well construction method:A-) K Z � construction to the following:
(i.e.au_eq rotary,cable,direct push etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276"-1636
13a.Yield(gpon 15 Method of test: I R- 24c.For Water Saintly&Injection Wells: In addition to sending the form to
��1n� the address(es) above. also submit one copy of this from within 30 days of
13b.Disinfection type:VA At Amount• W completion of well construction to the county health department of the county
where rnoswcted-
Form G W-I North Catalina Department of Enyimnmenul Qualitv-Division of Water Resources Revised 2-22-2016