GW1--03019_Well Construction - GW1_20230306

For Internal Use Only:
1.Well Contractor inforruntioDn:
I tN r r-�J 4/irzi `fit 6 i A 14.WATER ZONER
FROM TO DESCRIPTION
Well Contractor Name It-
WC Well Contractor Certification Number
15.OUTER CASING for multi-rased wells)ORLINER if a livable
YAOKIN WELL COMPANY,INC. FROM To DIAMETER TffiCIOVEsS MATERIAL
ft ft. in.
Company Name
I� 16.IlQNER CASING OR TUBING eathermal closed-too
2.Well ConstructionPermit#: �" ® `( �P FROM TO DIAMETER TEaCICiUS MATERIAL
:3
List all applicable well construction peiTnits CA EUC,County,Slate,Variance,etc.) I It Jr� it in. ®� v f,
3.Well Use(checkwell use): ft ft. m. /_
Water Su Well: 17.SCREEN
Supply FROM TO DIAMETER SLOT SIZE THICiINESS MATERIAL `1
❑AgricultnraI ❑Municipa"ablic
❑Geothermal(Heating/CooIing Supply) KZesidential Water Supply(single) ft. ft.
❑IudustriaVComrllercial ❑Residential Water Supply(shared) 19.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO DATERIAL EMPLACEMENTMETHOD&AMOUNT
Nan-Water Supply Well: ® ft' 0 3 ft' I-® e k • 14{ (-a 'S
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Reurediation
19.SANDIGRAVEL PACK(ffa livable)
❑Aquifer Storage and Recovery ❑SalmityBarrier FROM TO MATERIAL ESaPI.ACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLTNGLOG attach additional sheets if necessary)
❑Geothermal(Heating/CooUngRetom) ❑Other(explain under021 Remarks) FROM TO DESCRIPTION color,hardness,solllrncktypc, air sae,etr-
t Q C) ft. 0 ft. S®Be 1
4.Date Well(s)Completed: 2 b"a* )3 WellIDff 410'346 ft' n
5a.Well Location:
/f �- Phone # �� �®7q�®-��l� ft ft ft fL
-. -
i�
Farlity/Owner Name Farility]D#(if applicable)
rQa � ft. ft
�►��2.a �®Pr�1��•1 OA�� �C Grime, /r�v/g�+cS tt. ftMAR
tt ft.
Physical Address,City,and Zip ��.401 /?[����,Q,e
(� n 21.REMARTIS !fi:�o:•,,:::C
C
County Parcel Identification No.aTg)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) R 22.Certification:
3-S N 11 ?L?e W
6.Is(are)the well(s): O ermanent or ❑Temporary Siq. e of C tified Well Contractor Date
By signing thisform,1 hereby cert)�that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or KINO ISANC4C 02C.0100 or ISANC.4C 02C.0200 Well Construction Standards and that a copy
Tf this is a repair,fdl out brown well constriction information and explain the nature of the ofthis record has been provided to the well awner.
repair under#21 remark section or on the back of this fom.
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 CTW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled'- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if d�erent(example-3@200'and 2Q1000
10.Static water level below to '��� (ft.) 24a. For All.WeRs: Original form to Division of Water Resources (DWR),
Tfwoter level Is above casing,use p of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+"
11.Borehole diameter- (<' (in) Bit Off. 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyto the
(to.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUINV�
13a.Yield(gpm)
f Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
���
70%HTH - �� OZ DATE SITE VISITED: ���
13b.Disinfection type: Amount: v15�TEE
Pri r`t-. 17WYA BY: (�\
i A ru "`�