GW1-2023-01488_Well Construction - GW1_20230209

INVELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: —
1-Well Contractor Infojrm don:
:�� lV V� �lf� �✓ 14.WATER;ZONM
Well Contractor Name FROM TO DESCRIPTION `
m
NC Well Contractor Certiflggtion Number t i
FR0<i 70 DL4,METER THICK,VESS - MATERL►L
Company Name n• Z in. 4 c
J J .INNER CASII�IGOR T(1BING ebitiertiia7 closed-faap} ��. �
Z.Well Construction Permit#: _� FROM TO bIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC, Counq,,State, variance,etc.) fY, ft. in.
3.Well Use(check well use). rt. ft. — in.
Water Supply Well: 3Z SCREEN
❑AgriCUltural ❑14uniciDal/PubliC FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
twectnermai I•neaunglLoolmg Supply) CIaPResidcutia[Water Supply(single) -
ft. ft n.
❑Industtial/Commercial ❑Residential Water Supply(shared)
❑Irri anon 18,GROUT
❑Wells>100 000 GPD FROM TO MATERIAL EMPLACEMENT M THOD&AMOUNT
Non-Water Supply Well ft. ft.
❑Monitoring ❑Rccovcry )
Injection Well: ft.
❑Aquifer Recharge 0Groundwater Remedi an tc• tt 1�
ClAquifer Storage and Recovery ❑Salinity Rnr "
1 "A'r4'.AIAi. I ➢MDT�r DrRcf. m•e.rr�.. ..
(JAgmter Test --------- -
❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control --
❑Geothermal(Closed Loop) ❑Tracer ?A2;DR1 G LOG attach additioiialsfieets if necesaar'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESC Fn-S color,hardnef toll/rock rain size,ete. \
ft. ft. C, U
4.Date Well(s)Completed: ft. 01,
�
Sa.y{ell�ocatlon:r lI i�. ft. v
( � c
Facility/Owner Name Facility rD#(if applicable) ft. ft.
NO ft.
J
Physical Address,City,and Zip ft. R
,� RENARX&.
r.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds nr derin 11 rlaR.000.
22.[.er le fi10
6.Is(are)the well(s): Permanent or ❑Temporary Si of ertified e tractor
7.Is this a repair to an existing well: ❑Yes or 17No BY si ng this form,I herebya,15 c or 15A ertify thatA2�)O
well(s)was(were)constructed in accordance with
If this is a repair,fill out known well conslluction lgjormation and explain the nature of the of this�ecortlltas AC 8ee�provided tCo th0�11owner.
pair Construction Standards and that a copy
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
~A vu tLSY use the back nt this naae M nrm,;,IP
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional
drilled: pages if necessary.
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths ifdiffereni(example-3Q200'and 1Q100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level Is above casing,use"+ ' Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in) 24b.For Injection Wells: Conv rn nwu rtn,1..,,..,,.,,,,1 T-:_—:-- ..
{ .rn?ram
12.Well construction method: Q i r rn-rG -l/ -
(i&auger,rotary,cable,direct push,etc.) 24e:For Water Su I and O en-Lon Geothermal Return Wells:Copy to the
county environments heal department o e county w ere installed
FOR WATER SUP WELLS ONLY:
y / 24d.For Water Wells pEEducin over 10Q 000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: ��IW Permit Program,16l 1 MSC,Ra eiiggli N, C 27699-1611
13b.Disinfection type: Amount: