GW1--04111_Well Construction - GW1_20230623

•
•
•
WELL CONSTRUCTION RECO (GW-1) • For Internal Use Only. • , . • .
1.Well tor.Iaformatioa: I
•141 WATER ZONES --
Well Co Njtan°
FROM TO DESCRIPTION
Lf 5 Ti A- ADD ft.' $20ft.
NC Well Contracr tor CatifiationN er ft: it
Sy /; n ) 15.OUTER CASING(for multi-eased wells)OR LINER(ifap Gable) •
kILf I c i /W .t'/I— FROM W TO DIAMETER THICKNESS MATERIAL _
Nafr.Companyme !r I ft is
2.Well Construction Permit#: J 16 INNER CASING OR TUBING(exothermal doCed-loop)
N�. F 617(OO �a 2 3 FROM • TO DIAMETER THICKNESS MATERIAL
Lire all oppbeabkwell conrtruaioitpermits(Le.WIC County.Sane. aiance.ere) • -t•I ft tt•3 ft •s,/!( m. Ts
s-Crt Ti!'
3.Well Use(check well use): ft • g m•
Water Supply Well: • • 47.SCREEN •
❑Agicultural �I�2�micipaUPOblic FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL •
- ft ft m.
0 Geothermal(Heating/Cooling Supply) denial Water Supply(single) - - • • •
❑Indushial/Commeroial •
ft ' sc-
_ 'dential Water Supply(shared) 38 GROUT G
❑Iurgation OWells>100,000 GPD FROM TO EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
• ❑Monitoring ORecovery 23 �� /`s`; 'r
Injection Well:
P...r Z 4.i .l Y .
❑AquiferRecharge ❑GroundwaterRemediation • ft.
• ft
OAquiferStosageandRecovery • ❑SannityBarrier • • �.S�/CR OVELPACIC(ifappbiable) •
OA utferTest FROM TO MATERIAL EMPLACEMENT=MOD
q ❑Stormwater•Drajnage - ft. ft
OFxperimentalTechnology ❑Subsidence Control ft ft •
• CtGeothemlal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remadss) •
FROM TO • DESCRIPTION(calm bardaea sea/nek tract min sae,eta)
ft ft
•
4.Date Well(s)Completed: 6-43 4 3 Wen ID# • ft - r
5a.Well Location:. ' ft. . • ft
�.' TSca f�a %�, p .
a r i'1St� U--� ft,
• Fatality/ ame ' Faeflity DD#(ifappliable) ft • ft
' ems.; �d'�fi"'?1 �,r,-.r..,�.
•
Ck,/vi N tl& 2. (// --•ft . ft •d >..:.,I.q i k• ;Z L,/
Physical Address.City.#nd rip - R ft JUIN 2
Ct GC�'}7 •
,2LREMARKSIr ?�1� -
c my PareelldentifiatiofNo.(p1N) • • Inw'�,f??slC� trrw :53`'
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: s:_wa
(ifwell field,one latilong is sufficient)
3(p' l0' Z., N . fib' 22.certis
.6.Is(are)the wigs): ermanent• or OTern o 23
•
P MrY -(4.6 l Sim of • on Contractor Date
7.Is this a re to an Bastin •
Bysigningthirfoim,Iherebyce q5'that tSewell(s)war titers)constructed in acco dmuewith
P� g well: ❑Yes or , (No 1SANClC 02C.0100 or75ANCAC 02C.0200 Well Construction Standards and that a copy
"Air tsa repair,fill our known well construction Information and ocp(ain the Harare ofthe often record has beenprovided to the wail owner.'repair wider P21 no»aksmcdon or on the backofthisfonn. -
•
23.Site diagram or additional wen details:
8.For Geoprobe/DPT or Closed-Loop.Geothermal Wells having tie same You may use the back of this page to provide additional well construction info
• construction,only 1 GW l is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessaty.
dulled:
-
e 24.SUBMITTAL INSTRUCTIONS • ' .
9.Total well depth below land surface: 'L Q • (ft)
Formula:gewells list alldepths ifdlfjerrnl(er pk-3pa2��00•and2©lo0) -( Submit this GW-1 within 30 days of well completion per the following,
10.Static water Level below top of casing. Cod 242. For All Wells: Original form to Division of Water Resources (DWR),
Ifwaerlevelis above eartagiae+- ( ) InformationProcessingUnit,1617MSC,Raleigh,NC27699-1617 •
1L Borehole diameter. tol0./ • cal.) 24b.For Injection Wells:Copy to DWR,Underground
/() Program,1636 MSC,Raleigh,NC 27699-1636 Injection Control(lug12.Well construction method: ) l n i•'a t.., ' -
(e.auger;rotray;able.direct push,etc t 24a For Water Supply and Open-Loop Geothermal Return Wells:Copy to the •
county envzomnental health department of the county where installed -
•
• FOR WATER SUPPLY WELLS ONLY: ,
I •
24d.For Water Wells prodnung over 100,000 GPD:Copy to DWR,CCPCUA
132.Yield(gpnr) /Z, Method of test l All.- Pemu
tPr0gram,1611MSC;Raleigh,NC27699-1611
I'
13b.Disinfectiontype: • �-• 1 l4— , t/� � . .
t Amonat
'Form GW--1 North Canrm.fl•,•••..-. ems__...... -• --_