GW1--06705_Well Construction - GW1_20231024

WELL CONSTRUCTION RECORD(G f1 ' For Internal Use Only: ,
I.Well.Contractor Information:
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N5D 1)- Poo
I O . r � s• wood
PR CiYlOP
Well Contractor*MIS
-3--ict A. , ft. /00 it ,2...
ft. .. ft. i °1 -11 f'll . ,
1,tCIN Conmetor CatifteationNerober �! {-
CI(U 00 .e @ fp„,.., nr raletc,vsss MAC. ._,`. Rome tl R �' • I ib a1vi 'ieCompaQyllQame � /� ./� � /;r�y�. rvlJfINfOr S ., .Y '4 �K g
2.Well Construction Permit#: / (d V PROM TO DIAMETER' �cs s MATERIAL
List all applicable well tuna otion penults f.e UIC,Come'State,Variance,eta) ft. I In. .
3.Well Use(check well nee): ft. I lo.
Water Supply.Welt: f ``� 3 4"•,•, �;ar i, =�' X,� 'a g+"i�::.; +.+ 7` :1
1 now I In orloo f Fear l nl ss ).nsq.F,1. i
DAgriculte ral riuic-ipal/Publie ;,' Sr. n,?
$>
[IGeothem,al(lieatinglCooling Supply) dential Water Supply(single) ft. ft. 1n.
DrndustrisUConnmercial Mesidentlat Water Supply(shatad)
�� fl�w �.X�°�heF� �'2�`h' �;�,a�='v.;h'�.£�tisS�'.I�+.�si"� '�1»..�i4`hiet�'�;'•?,•,8•';:yY''���
C2lrriaatien C1Wells>100,000 GPD t TO MATERIAL EMPLAMPI1tc Oaerr , ior
Non-Water Supply Well: 0 it' Z 0 b$irfi r ra(Po
CIMonitoring DRecavery ft. ft. I • ( J
Injection Well: I ,
EIAqn'rer Rmitargp QGEmundwaterRemediation
. Jxrtrt 7kiiakatvi a'*ii;lia a ipaiizirie7 x ,t- F :. zr r*.. . -,.,;;r:r`:,l
ClAquifsr'Storage and Recovery UUSaiinity Barrier nu r�rn 1 A/A�r:afe! ! snem.AXcamwra t.., I
' ©Aquifer Test DStounwaterDrainage ft• ft.
°Experimental Technology DSubsidence Control' ft. Pt. I t .
OGeothermal(Closed Loop) C37racer s a aiti �r Y, j
OGeatheamal pL000ling Retool) DTther(explain under#21 Remarks) M° •-7° DESCRIPTION. , ON Ce�i;tiaren _solihoek traaeasm etc i ,
4.Date Well(s)Completed: Well ID# S 0 i
. r . A c9 a . c1 -,.t.-� .�..0....: -
5a.Weil osatia= k: v - r tr — , E ,n, .e . 1 v q, 9
1D � /AR� 1 TO 'f=. �a0*- : l$/CC1L.- rpc.k
FadtlitylOwner ame Polk ID#(if applicable)
.557 A [lodes tot Jew! l5`fa _ it.:'. , . ;.i , �a '' )
Physical Address, 'y,and 1p J ft. >G I f i.•1 `1 r
County Parcel ldentWcation No.(P/N) I i R,:;r;. . .;.;r ::''. ,p,l!e4:
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees: _..__'
(frwellfieht one tardong is sufficient) 22.CerdOcatlon: I
// N , .2,-, I0-3- 23
6.Is(are)the well(a): W ermanent or CiTemporary Si ...,.of Certified Well mractor Date
iysigning thts,lalmc!hersby cowl:ythat thewell(siaz,(wea)constructed in accord a with
7.Is this a repair to an existing well: DYes or Vo !SA NCAC 02C.0100 or 13A NCAC O2C1.O1OO Well Construction Standard,and t a copy
hernia is a raped:.OS oat known well construction d1 jcrniatlas and explain the nature ofthe ofthts record kat been pnovidedle the well melt
2-3.-Sire diagram or adtltioual cra'det
-L W u..� •�' !V:i way !ma'Ulu llDL'9. !L_._par RSV 1LE+L[7]I1QR81 W2.!'.yi/T4'ri-1Ft1,
'S K wr.'_i niys 7„wt4t•:or�,iv 1G-~1" t�i�v�ni ti�i��i.Y blYl Yi�.'Ml�.vµwM
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of evens ( 'Sec Over'in Remarks Box).You may also attach addilronal pages Fn
drilled: I 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth belowland surface: y 0 (ft.)
For multtpie welds Ust all depths lf different(example- 1200'and Z4100') Submit this GW-1 within 30 days of well completion per the following
I0.Static water level below top of casing: cS-0 (R.) 24a. For All Wells: Original fomi to Division of Water Resources •WR),
10.S(tamer twits aboys casing,use"+" Information Processing Unit, MSC,Raleigh,NC 27699-1617
11.Borehole diameter: ( Om) 24b.For InieFtion Wells:Copy to IIWR:ITndegrcuad Injection Con ,_MC)12.Well construction lon method: r tr t(-7 24c.For Water Supply and Open-Loop Geothermal Return Wells:C,., to the
(i.e.auger,rotary,cable,directpush,etc.) County environmental he8lth d oanmOnt of the count,where installed
•
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR, 'CUA
13a.Yield(gum) 0 Method of test: "( PermifProgratn,1b11 MSC,Raleigh,NC 27 99-1611
1•I3h.3Sletei fe/Hase hams! G V 9 - - Hx cunt $41.1 I
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