GW1-2023-02627_Well Construction - GW1_20230410

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Welt Contractor Information:
P, 14.WATER ZONES
Well Contractor Name APR 1 0 FRO31 TO DESCRIPTION
"'If.M; I
ft. S3/,5--ft.
_Ocwc
it')NC Well Contractor Certification Number D
15.OUTER CASING Ifor td1i-C2Sedi,iIU)ORL11tER(if ap 'e
T_
FRO,"U I TO DUMETER TMCKNESS ?,1"1MT.1A1
Walker WI /I FlIvIrOACA, fL ft. in.
Company Name
Me INNER CASING OR TUBING(Peollierniml closed-loop)
2.Well Construction Permit WivioCol ?,3 9 FROM I To DWAY MIR I THICKNEss T_xmTERiAL
List all applicable tivIlcollstri(clion permits(.p-UIC.Colmly,State,Mariance,etc.) LE I- I in. I
3.Well Use(check well use): f. ft. in.
Water Supply Well: 17.SCREEN
MOM TO mmurTEP
SLOT SIZE THIC
OAgricultural 0MunicipalfPublic 1-3 ft- 2 in.
Meothenual(Heating/Cooling Supply) DResidential Water Supply(single)
ft. ft: in.
Oindustrial/Commercial OResideatial Water Supply(shared)
18.GROUT
01nigation ONVells>100,000 GPD FROM I To ALVMRIAL EMPIACEMEMNILTHOD&AMOUNT
Non-Water Supply Well: 1 IL ft. 324
[15Monitoring DRecovery it. n.
Injection Well: fL ft.
0Aquifer Recharge IlGroundWater Remediation
19.SANDIGRAVEL PA (ifniinlicuble)
OAquifcr Storage and Recovery OSa,linity Barrier FROM I TO MATERIAL 17NMACE-slE9T 5JET110D
OAquifer Test Ostormwatcr Drainage ft. I ft.
DExperimental Technology OSubsidence Control " I t 19 "- 1CPA 1h Trimy"i-e- IQawrl�l,
Meothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessary)
DGcothermal(Heating/Coolitig Return) 00ther(explain under#21 Remarks) FIMM TO DESCRIPTION coins hardness.mil/rock stye etc.)Fpc,ar�ln stye
0,a ft. 33 X 7-.712 5_z1a wls,�,P_ "el le let5c?:5
4.Date Well(s)Completed: �_ IC6 _13NVeI1ID#t-JPZM106L8_ 3 3,5' ft. 145 5� rL
5a.Well Location: ed f, /.A'A
P,$L)(d —I, It- 100 ft. V
- of a W. 0!7 er7e(,,
Facility/Owner Name Facility ID#(ifapplicable) ('00 /-t4- :5
— Pee Pee R-4 Aber-4,-elv
Physical Address,City,and Zip ft. ft.
Sq7 q,c)-?c)012-3 2"RE"'ARKs
Counh- Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N 2 q W
6.Is(arc)the well(s): lVermiment or OTemporary fiedtil Contractor Date
form..
'ereki,cerdfy drat the ivellft)stas(tverq)constructed in accordance Ivith
7.Is this a repair to an existing well: Mes or ANo 15,lArCACO2C.0100orl5.4,%'CICO2C.0200 Nell Construction Siatidards trod that acony
lf'tlris is a repair,fill out biowi vull construction information and explain the nature of the of1his record has been provided to the wellouver.
repair under#21 remark section or an the back oJ'thisform.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-LoopAGcothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GXV-1 is needed. Iddicaic,TOTAL NUMBER ofwells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 'i4.SUBIVITTTAL rCSTRUCTIONS
9.Total well depth below land surface. 15o ft-) 2
For multiple wells list all efewlis ij'digerent(example-3@200'and 2@jJ00J Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 14n. For All Wells.- Original form to Division of Water Resources (MIM),
If irater lewel is above casing.use Information Processing Unit.1617 MSC,Raleigh,KIC 27600-1617
11.Borehole diameter: 7 (in.) 24b.For Injection Wells:Copy to D'WR,Underground Injection Control(IUC)
12.Well construction method: soft t C_ Program,1636 MSC,Raleigh,NC 276 99-1636
(i.e.auger,rotary,cable-,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return VvLfls:Copy to the
county environmental health department of the county where installedr
FOR WATER SUPPLY-WELLS ONLY: 24d.For Water Wells Producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(op m) iMethod of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount-