GW1--03839_Well Construction - GW1_20230609

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only-
L Well Contractor Information:
14.WATER ZONES i
WA ContraetorName FROM TO IDESCRIPTION
ft.
NC Well Connector CertiHcationNumber 1S OUTER CASlNG(for mdmcnsedwells ORLINIIt rfa ble
FROM DIAADIFR THICIQ�SS MATERIAL
Company Name. & TO ft.
in.
` I&JNNER CASING.ORTIIBING eothermal closed-loo
q -
2.Well Construction Permit#: yS 7V 4 A�' o�i � FROM TO DIAMErER THIC�ss MATERIAL
List all applicable well construction permits(Le-UIC,County,State,Varimtce,dc) �. ( ft- _14 IL in
3.Well Use(check well use): X/ H- 31 IL W ✓G
Water Supply Well: IM SCREEN
FROM TO DIAMIifflt SLOT SIIE THICIN MS MATERIAL
❑Agricultural ❑Municipal/Public —lot n. 3 fL
❑Geothermal(HeatmpJCooling Supply) Residential Water Supply(single) n in
❑lndustrial/Commercial ❑Residential Water Supply(shared) JL GROUT
❑hri 'on ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENTMETROD&AMOUNT
NimWater Supply Well: p M 2/ ft-
❑Monitoring ❑Recovery ft. IL
Injection Well: •
n rz
❑AquiferRecharge ❑Groundwater Rtmiediation
19.SAND/GRAVEL PACK f a ble
❑Agmfer Storage and Recovery OSalinityBarrier FROM TO MATERIAL ENWMC3UMNWMOD
❑Aquifer Test ❑Stonnwater Drainage At � iz -W a f
❑Experimental Technology ❑Subsidence Cotltrol: ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if
OGeothermal eating/Cooling Retu m) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color.tur&es9,soWmek sire,eta
q IL 10 ft. �L
4.Date Wells)Completed: 1 Well IN Gild �/ ��e
5a.Well Location:' 111L &0 fL
JIL
>l:
Facility/Owne[yNya�me Facility ID#(ffapplirable)
yG
Physical Address,City,and Zip y n. J V I V V 91023
��a�G�D.���S•Sl/ IARKS
Ylt.c>scT 7L lntor1r.-gran Pro Pronewg Ora
County Fared Mentifiration.No_"D p
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(rfwcu fiel(i,one Wang is sufficient) 22.Cc Lion: 1-164t� �
3S N ?9'e38' A/0 ' w
ee-2-.Z�
6.Is(are)thewell(s): Mermanent or . ❑Temporary Siguatn ofCertificd Well ontra.=
*Date
Bysig ungthisform,Iherebycertifyihat thewell(s)was(were)consimciedw accordmicewllh
7.IS this.a repair to an existing well: ❑Yes- or MNo 1 SANCAC 02C.0100 orISANCAC 02C.0200 Well Canstrudion Standards and that a copy
Ifffm is a repair,fill out brown well construction it formation and e*l—the nature ofthe ofthis record has been proyided to the well owner...
repair under#21 remarks section or on the back of9wform.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page,to provide additional well construction info
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells ( Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SU hffffAL INSTRUCTIONS
9.Total well depth bellow land surface: v Q 9 (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list aU depths ifdiffe—d(esmnple-3@200'and 2Qa 100)
/ 24a. For All Wells: Original form'to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) information Processing Unit,1617 MSC,Raleigb,NC 27699-1617
Ifwater level isabove casing use +
Pro For injection
MSC, eller C NC to DYM.27699 undmVqund Injection Control(IUC)
11.Borehole diameter. f n:) ', � - oPX.
Program, Ph, -1636
12.'Well constracfion method: 7'> a,4/4:t?4A:!!= 24c.For Water SaDD►y and Open-Loop Geothermal Return Wells:Copy to the
(.e.,m*cr,'rotaryr,cablr,direct pdsb ere) county environmental healtli department of the country where itatalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells-Droducmg over 1WA110 GPD=Cap}r to DWR,CCPCUA
AA�D i of test:/ YY
0 , h,N6& mm T 1611
138.Yield(gpm) VEyrIethod
136.Disinfection type: Amount: j v2_
Form GW-1 North Camlma Department ofFirizomnental Quality-Division of Water Resources Revised 6.6-2018