GW1-2021-02812_Well Construction - GW1_20210810

RVELL CONKRUMON RE Gw-1 For I rnal Use Only: �.
L Well Contractor Information: "
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ater Supply Well: ;;17.S(�8S11I r:.: {
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(H�C�mg SMAY) OR= water Supply(single) R io
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Vkrigation ❑ >100000GPD FROM i To MA'18RiAL IMIACMMMMODaAMOUM
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injection Weil•
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QAgrriErt Storage and Recovery 13Salk tyBarrier 19.SAPID1C,dtAv&L
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OAquiSerTest C3S=mader Drainage R R
OEgxrimaotal TachndoV OSubs dence Control R R
OCkothemnal(Closed gyp) C3T=r LOG attieh additio®al atie4ls`itF' ':
❑ (EeatingCooling Rettua) ❑ (explain under#21 Remarks) FROM To a rrox core swi/r.e1c eee
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4.Date Wells)Completed: -10 -7/ W ilia R tt
52.Wen Location: R R
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Fam3ty/Qevner Name F,c9fty MO(ifq*hcable) ft. R °
Pltysial Address,City,aodZip R R ,
y� 21,RB111A885: Or
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5b.Latitude and longitude in degreeshninutes/m onds or dee®al degrees:
(ifwren&K am l VIM is snfficieft) ' 22.Certification:
91
N 2 3 ., W
6.Is(are)the welt(s): ermeaent or OTeim porm'y 2� Sigoatme VeII Dam
aysigmigrJ6sfonr;ly.,,,6rtnrrhewau(s)wvs(wem)cmavu mabia000A mewtrh
7.Is this a repair to an erisfiag well:, •=es L L7 o 1SANGLC 02C:0100 or ISAJVCAC 02C.0200 WeQ Cgvnvumon Srmdads and der a copy
If dds fsa npalr,jm mib O > omraszrtaa an d esplmo-,the,roaoe ofrtx of Aria rec»,dhas bmr provided to due well owner.
'?!parr miler#21 rm arkseaftmt or the6=kOfthfs
23.Sine diagram or additional well details:
8.For CvmWobdDPT or Closed-Loop Geotherm I Wens having the same You may use the back of this page to provide additional well construction late
construction,only 1 GW 1 is needed. 36didte TOT LL NUMBER of wells (add'See Over'in Remarks Box}You may also attach additional pares if necessary.
drr7lcd 24.SUBMTITAL WSiRUCTIOiHS
9.Total well depth below land surface: (ft)
For eminple,*&Est aU deeds rfaff&e u(m=plt.3@2 'm d2@IM Submit this GW 1 within 30 days of well completion per the fallowing:
10.Static water level below top of cashW. (�) 24a. For All Wells: Original fens to Division of Water Reaouaoes (DWR),
to as elbows �e +i hsf miation Processing Unit 1617 NEC.Raleigh, of 27699-1617
1L Borehole diameter: {m.) 24b.For Infection Well=Copy to DWR,Underground Injection Control(RTC)
Program61636 MSC,Raleigh,NC 27699=1636
a well contraction method: o t a t" r
C -VV._mw,-W&reap-%eta.) 1 24c.For Water Saodand Oxen-Loop_Geotbermal Reta im Wt Cepy to the
county envuonmemar halm aepactroent of the county where'm [eel
FOR WATER SUPPLY ONLY: 24d.For Water Wells rode' over mm GPI):Copy to.DWR.CCPCEJA
134a.Yleld W* ? Method of test ;y- Permit Program,1611 W 99- 11
13L Dbb*cdon type: ! Am t t�✓
FomsGW-1 North r Dept ofEnvao==ul Quality-Division of Water Resources Revised 6-&2018