GW1-2022-06395_Well Construction - GW1_20220603

CONSTRUCTION RECORD D (GW-1) For Internal Use Only:
1.Well Contractor Information:
'� C& 14,WATER ZONES
Well Contractor Name 1rROD4 TO I DDSCU=ON
1 4
xc Well Cm:cutisea nmbQ U�' ri� �
15.OUTER CASING rfor—mjqfi-cased w ORLVaR ffBp )irshle
YADKIN WELL COMPANY,INC. FROM TO .moo -= TMCK?ws MATERUL
ft ft in.
Company Name
16-neMR CARING OR TUBING thermal dosed-loon)
2.Well Construction Permit##: 31*54I FROM TO DIAMz= TMCMMS NfATM UAL
List all applicable well construction permits(ce.D7C,County,State,Variance,etc) M 3 P/ iu. (raV`S
3.Well Use(checkwell use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMYLER SLOTSIZE .TSICtIN1S9 MATERIAL
❑Agricultural ❑Mimicipal/Publio
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑IIS1gati0Il OWeIIs>100,000 GPD I+ROM TO MATERIAL EMLACEMEMTMETHOD AMOtWT
Nan-Water Supply Well: © ft ft. t'"
'elllf
❑Mrmitoring ❑Recovery rZ ��
Injection it RA ft -Well: 't '
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Harrier 19.SAND/GRAVEL PACK da licable
RROM TO I EMYLACM10NTrd=OD_.-
❑Aquifer Test ❑stoner water Drainage
❑Experimental Technology OSubsidmc6 Control ft it
❑Geothermal(Closed Loop) 0-Tracer 20.DRIIMINGLOG attach addihmud sheets iftekessuryl -'
❑Geothermal(Heating/COoBngRrtmn) .00ther(axplaur under#21 Rtmada) FROM To nasr3z Tox�ta�t,eranea miliraetc
1P ® ft 2.1it r
4.Date Well(s)Completed Well1D# /{� Z �. ft. I .. -e;-
5a.WellLocation: Phone# Dint 941C
Facility/OwnerName /, ga�yil*&V'pj�ble) ft. t i
CA
PhysicalAddresa,Cidy,and it rt o
2LREALU Tfp
County Parcel Identification No.(PIN) _..
y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^� ^ +��r '• r, �wZ 1 i�;'
(ifwell field,one lat/longis sufficient) n Lrue➢'Y wra i i:v.e� ...
22.Certification:
36 l i, N_ 91 3 . So.�l W
6.Is(are)the well(s): ermanent or ❑Temporary 5ignOn a of Certified Well Contractor Date
By.rigningthisform,I hereby cenTy'that the well(s)was(were)contracted in accordmtcewith
7.h this a repair to an eidsting well: ❑Yes or Io I Sf!NCAC OZC.0100 or ISANCAC 02C.020D iPell Construction SYmrdards an. 191 a ropy.. . :,
,phis is a repair,fill out known well construction information and erplafn Me nature of the of this record has been pravirled to the well owner.
repair under f2l renrmkr sedian or an the back ofThis form.
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 will construction info n'
construction,only 1 OW-1 is needed Indicate TOTAL NUMBER of wells (add'See Over in Rcmarl6 Box).You may also attach eddifiorial pages if necessary; X=�
24.SUBMrITAL INSTRUCTIONS
9.Total well depth below land surface: T (ft) Submit this GW-1 within 30 d of well coin letion
Formultlple wells list all depths if•dlffnent(eramp/e-3(a)200 and 2®I00D p per the following:
10.5tatiewater level below tap of casing:_ � (ft.)
24a, For All Wells: Original farm to Division of Water,Resources(DWR),
/(water level Is abave casing,use"+" �" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 0(4� (i -) Bit Off: J. � 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,I636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12,Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy tothe
(Le.auger,rotary,cable,direct push,eta.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: _ 24d.For Water Wells producing over 100,000 GPD:Ca D
5 Permit Program,1611 MSC,Raleigh,NC 27699-1611 Copy to �7R,C C ECUA
13a.Yield(gpm) Method of test: �t;�•�
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
Pri r-P