GW1--04113_Well Construction - GW1_20230623

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WELL CONSTRUCTION RECO (Gw Y) . I For]hte,nal Use Only. 1 ,
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1. Contractor. lion: ,
L. � ,
�.. 14W
Well ContraotorName WATER ZONES -
FrtOM TO DEECEUMON •
95ci7- A •
sow' ft
C Well Coutru tor Cerdfi Number ft ft
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Is.OUTER CASING(for multi-eased wells)OR LINER(if ap Iicable) •
At IMAM ���/ ft.FROM I TO 'I DIancrEB. I •rwroc�Ss MATERIAL,
Company Name V f.
2.Well Construction Permit#: �p (Al 116.INNER CASING OR TUBING(reothermal closed-loop)
Luialll CUcablewell Per ui permits(La MaM
DIAMETER THICKNESS MATERIAL
Cam%Slaiq Variance,etc) .-L ,ft. cteft.
fY in' • /C.✓` ,h..
3.Well Use(check well Ise): in. /
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Water Supply Well: .7_SCREEN
❑Agricultural OMlmicipaUPablic - FROM TO DIAMETER SLOTSIZE TRZCRIVESS MATERIAL '
CI Geothermal(Heating/CoolingSupply) �� Supply(single)ential WaterftI. f. _ in.
['Industrial/Commercial
ial fr. ft in.' .
ential Water Supply(s�4 18.GROUT
❑Imgatioti. ❑Wells>100,000 GPD FROM TO I MA
Non-Water Supply Well: ' ^ EMeL+ncE^nzfxr Metso/D AMoimr
• ❑Monitoring ORecovery •
l/ fi- 2• '"`.y"�i /V L , f.'l •
• Injection Well:
fa I r ! %( D(�(,-.�.
❑AguiferRecharge ❑GmundwaterRemediation 6 T
❑Aquifer Storage and Recovery • ❑$a yB a 19.SANID/GRAVBLPACFC(ifapplicable) •
❑Aquifer Test FROM TO MATERIALLA EmceM METHOD
FROM
l ft g
❑ExperimentalTechnology l]SubsidenceControl ft ft
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• °Geothermal(Closed Loop) ❑Tiaeer 20.DRUZING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/CoolingRettma). ❑Other(explainunder#21 Remarks) FROM TO DESCR1PTiON(tolar.hardoeu.sa0/nektipe paiosae,eta)
f ft.
-•2 3
4.Date Welks)Completed: Co -. Well ID# ft. ,
Sa Well Location:
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!D St•�e[1 r�
LlL hc,, ft ft •s -.+� tt�v�
1 .
• Faci�ity/OwnerName FaciityID#(ifappliable)
ft ft JUN ? "i• 21173
O t -TM i 0 k ire- -# (41( ...IL
ft
Physical Address,City.and Tap ( ft. . Init.,ti.,ea..i...i i 1,,-...,:•un.,rog lit r i
(A)./ 1./7 • ,2Limams/ G�D�`t+tSLtii�
CountyPusolldentifiationNo.(PIN) •
' Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latilongis sufficient)
22.C
_Sip' 3/D 80 N r��• Q 9... ." /37 W I •
6.Is(are)thewell(s): 'ermanent or ❑Temporary :.. ..,'o£ - •.;, a,Co ^ �� Z
3
Si
nhaetor Date
7.Is this a repair to'an existing well: ❑Yes or Bysgningth oim,Iherebyare)9 that the well(1)war(were)conrtructedlnaccordan ewith
o LS,tNCdC 02C:0I00 orov;edt0 Cthewell2C.0200
owner.
U Corrrtrucnon Staidadt and that a copy
repo ism repair dill out known well construction irfos»a n. ondexplain the nature ofthe of this record has beenprovidedto the well owner:
•repoirunderOf remarks section or on the back of this form.
: 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Nosed-Loop Geothermal Wells having the same You_may use the back of this page to provide additional well construction info
• drilled:construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remadrs Box).You may also attach additional pages ifnt.cessatp.
9.Total well depth below land surface: 2...a
/ • 'SUBMITTAL INSTRUCTIONS • '
For multiple wells Art all depths jdlf a errt(ermnp/a.3�p•and2(aj(00) -(ft) Submit this GW-1 within 30 days of well completion per the following
10.Static water level below top of easing 60 • ( ) 24a..For All Wells; Original farm to Division of Water Resources (DWR •
lfworerlevel is above eo,j, ice+� IaformationProcessing Unit,1617 MSC,Raleigh,NC 27699-1617 • )
1L Borehole diameter: 11c,
•(n.) 24b.For Infection Wells:Co to DWR, ,
Pr'ogram,1636 MSC, N -1 Underground Injection Control(IUC)
12.Welt construction method:_ ? •D�—a►�, _ A- -- Raleigh,NC 27699-1636
(r a cage;rotary.able,direct push.eta) —� 24e.For Water So and 0oen-Loou Geothermal Return Wells:Copy
county environmental health department of the comity where installed to the •
' FOR WATER SUPPLY WELLS ONLY: ti
' 24d.For Water Wells producine over 100 000 GPD Copy to MR,�pCUA
132.Yield(gpm) /U Method of test: �ln; P�utProgram,1611 MSC,Raleigh,• .27699-1611
13b.Disinfection type: l'"I a' Amount d !- - t s
Cy-, , ,
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• 'Form GW 1