GW1--07368_Well Construction - GW1_20231113

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WgLL CONSTRUCTION RECO (GW-11 •
IFor Internal Use Onl*F .• • • - • . , .
1.Well . Clor.Informati • • - • I . - • I j -: .
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. .tioViiirATER
. . 7 Zs9oRES ' Ili ti iii•s ow • . _
Wen CO 7 anis • . . .
AO Datil l• . • .. .
4-5 q —A • /00 ft7-I
ft_ ffr-il L 1 • . .
ricw.ftc.,.....„
ajQINubcr •. ls.017TER CASING Geersieild-eesed wells)OR taint arm. rutobiei • •
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PROM I TO CIO DIMWITS= I THICICHIESS
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CAimpargyN IIIIIasue •
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16.DINER CASING°ATOM:NG(geothermal dnied-loop)• . • -
2.Well Construction Permit i 3 /C Colonyg5a,Mjate.e . ROM ft TO IAMn 1:RC/K7N,E0S,., IMKIEILLLn all appcable welleuona rairme -1-I cats Ir .-- 77 •
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3.Well Use(check well use): ' " ft. ft.
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%terse piiiy•sell: .17.SCREEN II li ' • ' '
PROM*. [TO DIAds7R SLOT SIZE IIIRMNESS MATERIAL
: • 'ClAgricultural 'ClMimicipal/public
ft' • IIIII Et • , ,
0 Geothemial(Heating/Cooling Supply) ......Eeential Water Supply(single) .
. ft ft I L in: . ' I . • .
°Industrial/Commercial • identialWater SuPPIY(Shared) 18.GROUT "
Card 'cnEaiL..._._....._._.___(r >MO NO GPD . .. . ellsFROM TO MU .• Etamtannarr?ammo&Ammar
Non-Water Supply Well:. •• •
." • 0 ft• ft. r4 ,Cee- ")4;r (
• °Monitoring . ft • ft
°Recovery. 2 • injection Nve, "
' ft a 1-•//4.1.4• /9440?-7...J
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. 7 OAquifer Recharge OGroundvrater Blinediation
19.SAND/GRAVEL PA=Of attainable) •' -
°Aquifer Storage and Recovery • OSalinily Bonier -
FROM . TO I :Rid.AIZRLAL =PLACEMENT MITROD
' . °Aquifer Test ., • ' OStormwatcr:Diabiage „- . •. -- iL II . • ..• • • . • • '
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OExperimental TedinologY 0Sulisidence Control . " VVV' ft'. I • • ' • ,
(;1•Geotirmial Posed Loop) 'V • °Tracer 20.DRILLING LOG(attediladditional sheets if necessary)
•II ED17CRIPM. ON(War.Lyda, cis,raked!.woe..vote she.ete3, • .
• °Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) PROM TO
' ft ' ft• IU : •
4.Date Well(s)Completed: ii—4- •••'1 Well Io# • ft. •ft IF • .
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Ss.Well Location: ft.
• I t 1+1-N R`e e V 4-5 • . .
ft ft• IIF ' . . . ..
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• Forolity/OvnicrNamo Pocility MO(tiopplicable) . ft. - ft. la ii .!, tt:.+•N:t.::'f.,,'",„".:ti,-„„.--r;:V if2.2,
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* 14-U ''''II"/.----/?s"he Stv6.1,-,p .il . ''.ft. . ft.
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PhYdAAddr‘ae!a!edriP 'Pi h e icrid pro ft,
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ft 1111,, /02,3
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.. mi:,II b.3..,. .i.F.,t, ,. ...,A...=`,:.•v.:::9,_t,-,1i,,:t., , ., •;:.,.
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County ' ' ' '
Parcel IdentifuntionNo.(FIN) cE,, . i ',? ', "
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•. 5b.Latitude and longitude in degrees/Minutes/seconds or decimal degrees:
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(ifwen field.oco lat/long is suffsekat)
22.C. ' , • '. . I, • ' . ..
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310. I t•a itl'. 81 ' 2_g` 3 -
N ,.. W . ,. •
csAirt(Zif. i; : ' ii—6- L3•
cop .•
6.Is(are)the well(s): rmanent or OTemporary 31 86/ Sigaawi`61 ' ea aut rj Date
Bysigning shirform.1 hgreby that thetreU(s)war(were)connruered in accord 'ran, .
7.Is this a repair to an existing well: °Yes or teltr ISA'CAC 02C:0100 or7.54 C 02C.0200 Mil Cfessolicrion Swaim*aYagog a coPY
If this ir a repeirdill out known well eonraustion information wdlgjis abs nature of the ea*rewrd has bernrdvvi ;the weil"ner• .
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• •repair under On ranorks maim or on she back qf dal:fora
23.Site diagram or additiolnl well details: .• _ . . - •
You may Me the-babk of tllis liage"to provide additional Well construction info
8.For Geoprobe/DPT or Cl. osed-Loop'GcotberniiilWellibaviirg the same . .• . construction,only 1 GW-1 is needed. Ltdicate TOTAL NUMBER ofwells ' (add IS"0.vce al Remiarks r.IrcRimaY also. attach ac.idilional PageS 4neCeSSMY- ,
drilled:
24.SUBMITTAL 1NSTR crzoNs • V , . .
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II days
. 9.Total well depth bdow land surface: 2:-2-0 '
Submit this GW-1 Nyi"thin i a of well completion per the following:
FOP DIU16221C weUr list all depths Offerer:I(ceampk-3@a00'anti 2@l009
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10."Static water level below top Kcasing: I+A . (it.) 24a. For All Wells: Original form to Division of Water Resources (DWR),•
Information Processing Hui 1617 MSC,Raleigh,NC 27699-1617 •
Iiirater kvd is above earinCuse"+' •
11.Borehole diameter: 12• 1/e On-) • • 246.For Injection Wells:Copy to DWR,Underground Injection Control auc)
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Program,036 MSC„Ralei NC27699-1636 .
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12.Well construction method: i'c Cri rE-1 — 61_,t,
24c.For Water Supply and! tpen-Liop Geothermal Return Wells:Copy to the , •
(i.e.uses rotary,cable,direct pork MO
county environmental health department of the county%Mere installed , • •
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• FOR WATER SUPPLY WELLS ONLY:. . • • 24d.For Water Wells ro nein over 100 000 GPD:Coy to DWR,CCPCIJA
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• aProgram,1611 MSC, eigh,NC 27699-1611 . 0 -
13a.Yield(gpm) EL) ' Method of test CLA..... Pam.
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131i.Eisin' fection type:_Lt124- :1_ Ailifoun • .. •1--r.-7.--' •I . . •
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Prom GW-1
Nardi Cazolini D'spartmtait OfEnvitoomental Quality-Oirition ofWatorReseurcM • Revised 6-6-20t8
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