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GW1--06705_Well Construction - GW1_20231024
WELL CONSTRUCTION RECORD(G f1 ' For Internal Use Only: , I.Well.Contractor Information: ' 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 / 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 I 1 1