GW1--06176_Well Construction - GW1_20230922

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: '
L.Well Contractor information:
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FROM TO DESCRIPTION
Well Coent�rnotarName f. t i fo ft. 15 i _�m
ft. ft.
NeWell Contractor Certification tunber �Eit;:er• I1Yfatfgi�1ti�dlf 5ed=tvl'lts_):i)g R-jtf_AAfi4 11bT �° "
n ,�`�/� t PROM TO D�iMP2ER THIGii;7Ec il7ATLIiimiz41: .
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2.Well Construction Permit#f: FROM TO ' DIAMETER ; THICKNESS - MATRAiaT
List all applicable well construction permits(le U!C,County,State,Variance,eta) ft• ft. in.
3.Well Use(check well use): ft. ft. 1 is im , iv •c � .,'7 ,,,,,.r'4+ u,. + § ,, _
. .t u oorr .;:. a � 4,:t ra.vti:... 6Yx kzt,ria ,f .i4 Water Supply Well: FROM TO DIAMETI R' SLOTSIZE THICKNESS MATERIAL
j
❑Agricultural ❑Il1unicipal/Pablie it, it... In. f
DGeothennal(Heating/Cooling Supply) (Residential Water Supply(single) lr tt w ft. In.
Dhtdustrial/Commerciai DResidential Water Supply(shared) yy.•n,,h��zrrym,. `r Y
... :,�:Ri1��.0 i�).`�.ij.1.r�? rf}.�w, i'�J* „+r'•u"`�r�- t.----ti-- .�_ r.z t^;- ,Jf i.,.
Cifirikation CiWells>100,000 GPD FROM TO MAT EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. � h' 6� oh rru C /� .
❑Monitoring ❑Recovery ft• ft ((
Injection Well: ft ft. �(JJJ ,
[]Aquifer Recharge ❑Groundwater Remediation <,r y
't'a6iSii►1i010avJ�1llitl ViiiiiiiiiiEiblis+:rF..W'�a yc ye614`-2«`Lti.�i?3rti-'"$rv.,:. Ail!,
°AquiferSitnrag nor Recovery OSalInityBarner ono e 1 TA 1 MATfnnlAf. I H.MPT.Ar!aMRNPbiILTtrnn
❑Aquifer Test DStormwater Drainage n: ft• ' '
DExperimental Technology ❑Subsidence Control ft. St. r ;
- ❑Geothermal(Closed Loop) °Tracer gAftaixatIliviariodliftadiiiirdftftifaisiiiktia4tailV4wAvgavAaiiTil.EfF
FROM To DESCRIPTION color,hardness,aoillrock type,min dze,eta)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) it. "
4.Date Well(s)Completed:CC✓a`�"�S Well 1D# aQ n' /f)d n' c i et
5a.Well Location: OD"'. ` /°d[t-f�k
Lire i<tke,S
Facility/Ownert he . Facility DV(if applicable) ft 1 ft. }"" •"` t 1•
Physical Address,Gity,and Zip y ft: ft.
v N b " I 3 Li 5 0 Li 3 TS t fi �".�md*°fit l^? r- '•'�`�);wY'`��-3. `' .tram+'t.;� p ✓.,;,,, 3F s #iS1Y''; :.
1
Parcel Identification No.(PIN) CA alt f ''
l.atitnde Rue!1nugifluie fn decrees/minutes/seconds or decimal devreeat
(ifaieD field;one iar/iong is sufficient) 22.Certiiieationt;
4 11 V . , .r,deiv
,, , ,, , _._ D:5 - )3
6.Is(are)the well(s): ermanent or ClTemporaSt:,-i rr of Certified Well Contractor i Date
By signing this form,I hereby cart(fy that hewell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes orAlo ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,,rill out known well construction Information and explain the nature of the of this record has been povtded to the well owner.
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details;
S.For C o`rahe.,'DPT or Closed-Loop Geothermal`.'ells having the.sanre 7""`,u. ueu u.r,Urge,w.uufl a.++a.vqn y a.•.w •..a. +a w.w
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Civet'in Remarks Box).You may also attach additional pages if necessary.
wed: i 24.SUBMITTAL INSTRUCTIONS
J.Total well depth below land surface: (f ) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Vdii different(example-9©200'and 2 aC3100)
10.Static water level below top of casing: 20 fw 24a. For All Wells: Original form to Division of Water Resources (DWR),
Order10.St ;welts above casing,use op ( ) Information Processing Unit, MSC,Raleigh,NC 27699-1617
Ttnrphnla diame fare CI) Rn•1 t 24b.For Infection Wells:Copy tl DWR,Underground Injection Control(IUC)
- SEt] m..tn+n lv!tcr naleliity evi.i,u»-is,.,u
12.Well construction method: a(r rat te� 24c.For Water Supply and Open.Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etck) county environmental health department o(the county wfiereinstafed
FOR WATER SUPPLY WELLS ONLY: , 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
1'6 1A1
Permit Program,1611 MSC,Raleigh,,NC 27699-1611
9
13b.Disinfection type: a1+. - Amount:�2. l ff1 ,
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