GW1-2023-00683_Well Construction - GW1_20230113

WELL ®NS 1TRUCTION RECORD GW-1 For Internal Use Only:
FROM To DYSClRUMON
1.Well Conntrrscto�r Information:
u /' e U A�T U.WATER Z(INP6
Well Cmtraetn Name
31D R y R So e�
a-s7a.4 R R
NC Well Counaator Ceetifiutiaa Nmnbc M OUTER CASINGfor mul6-uaed welt OALINER der Ruble
YADIGN WELL COMPANY,INC. FROM To DTAMEffiE TffictrTras MATERUL
ft.
in.
Company Name It"-79oT t; ILEO RCASINGOR TIIDING thermal rloaeMoo
2.Well Conatructior Permit#: ��ST� —2.727_ tEOM TO nlAMaaa THIOB1aZ8SI MAT1mrAL
Lid all applicable well 001iMudion parmils(Le WC,Corny,&M,VCKMm,e(cf 44 R Jt
3.Well Use(checkwell use): R I ti' is
Supply well: F ts'CREEN
Water Su
PP FROM I To I outdrrEE i st.OT s¢E I razcTwess MATERIAL
DAgricultmal O..MJJimicipaWublic R. I R. I Im
DGeONemml(HedWCooling supply) l3Eesidentiel WaW Supply(single) R I R. is
olndnatrial/Commerciai ORcsidmtial Water supply(shared) 1L GROUT
chrigation I7Wells>100,000 GPD FROM I TO MATERIAL EMP ACEMD"METHOD&AMODNT^
Non-Water Supply Well: V ft. R n,C�; V✓C.,
oMonRarmg oRacamy R r,
lnjection Well: R I R
oAquifer Recharge I]Groundweter Remediation
39.tsAPIDK'EAVEL PACE der Iieable
DAgnifer Storage and Recovery ElSalindy Barrier FROM TO MA'1ERIAL EMrIACVUNT METHOD
❑Aquder Test CStormwater Drainage R R
OBxpelimmital Technology oSubsidence Control R ft.
110cothtrmal(Closed Loop) oTra= 20.DRMLINGLOGatiach additional sheets if neeena
OGeothermal(Heatiag/Cooling Ramon) oOtha(explain Emda#21 Remarks) FROM m Dssr�Trox aEvr na.meaa,maAae>< ate. �.
R R r
n 40 O
4.Date Well(s)Completed:! 10•a-,-W a iow !e' $'
sa.WellLoeation: t Phone #336-1-YV. 3oglf 8 R
R ft.Te R x Aem Wen 4 U
--� Pscdiiy ID* R tL
eammyrvwnaNamo -..
2,111 44 R a 4, Li, t It ^
Physical Ad&-k City.and lip R R JAN CY
Yn 1 I, ,^ 2L AEsaAM
CU*' �s M Paeel ldeaEfica4on No.(PD7) .
Sb.Latitude and longitude in degrees/minutes/secends or decimal degrees:
(if well field,eoe Ia llongis sufficimt) 22.Certification:
36 - / Y `s-2,8�1v~ 80 30 ' 2Y. JL" w y/-y -, / 1-"(e•
f9Y )/x
6.Is(are)theweR(s): ermaneot or oTemporary Wdl Contractor Data
JJ llydgnbrg thisfam,]hereby certify that the well(s)was(werel constructeain accordmroe with
7.1s this a repair to an e:dating well: oYes or COVo 15ANCAC 02C.0100 or 15A ANCAC 02C.0200 Well Construcilm Skndardr and that a ropy
If thin b a repair,fell out known well condraanon information and erplabr the nature of the ofthis record has bemprovided to the well owner.
repairtmder 1121 mmarkr section or on the back ofrhirform.
23.Site diagram or additiond well details:
8.For GeoprobrJDFT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction i➢fo
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ov e inRemsda Box).You may also attach additional pages ff necessary.
dulled: / 24.SUBMITTAL 1NSTRUCI7ONS
yoze fL L�
9.Total well depth below lard surface. ( ) Submit this GW-1 within 30 days of well completion per the following: X
For mulllple wells list all depdrs/fd�eren((®rrrpfo-3Q200'mrd7®100') \
1
10.Static water level below top of easing: Iffle r (iti) �• For AR Wells: Original fora to Division of Water Resources (DWR),
ywater laud Is above casing,use"+• Inlmation Processing U.A 1617 MSC,Raleigh,NC 27699-1617 \
11.Borehole diameter- (in.) Bit Ofir.4 s 24b.For Nection Wells: Copy to DWR,Underground Injection Comm](BIC) 4
Program,1636 MSC,Raleigh,NC 27699-1636
11 Well construction method: AIR ROTARY
to aW.�'Y.oabk dv<upwk ec) 24c.For water SuDDiv sad depeo-LooD Geothermal here] Wells:Copy m the
( rowdy tunvuonmental lmalth department of the county where mstaLLed v
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rod
�
13s.Yield(gpm) ucin over 100 000 GPD:Copy to DWR,CCPCUA
7 Method of teat: .)' QT/ Pemut gem,1611 M3 Rdeigln, C 27699-1611
G
Q
136.Dieinfectioa tppr. 70%Hlli Amount: /�� OZ DATE SITE VISITED:
V,4 no _ VISITED BY: nag