GW1--07871_Well Construction - GW1_20231205

W1,114 CONSTRUCTION RECORD(GW f) For internal Use Only: ' i
1.Well Contractor Information:
Wen Contractor Name PROM- TO DESCRIPTION
a-1 q A
. ft. 1 i •
NC Well Cone =CGCtelestianN{ i.berg i�Ce.tAY,M1YNTR.,fR`�l,TXfYAiit_=� 7 :-_imaA11i,,31ti-11'./IiRAT,'•! :,.. -
f' it, \j O i @kmf t ,9jr �71:10 ft' � it. Lit°
zain. cr:. s3 ;aTxt,� ,CompanyNamet Vw.
2.Well Construction Permit fir 10 PROM To DU MMER THICKNESS Mnzsnw.
Ltrt all applicable well conatruetton pennies(ta.WC,Count,Stag Varlance etc.) ft. ft. . In.
3.Well Ilse(check well rue): fu ft. I. In.
Water Supply well: rtIViairgtata0MF-lar
sad, gar r�,: . :TO 1 xriA.4,...sM,ni rstalr,...1.4...s/a..t.ss. ��- i ltYlt+l�6 T1IICJ 1HA �r, 1
©Geothermal(Heating/Cooling Supply) esidential Water Supply(single) { $
t]Indust:ial/Cornmercial DResidential Water Supply(shared) :I. in.
e •ia, •„."11,fitafrimmestwoit",,00.0:,.coorar,atzt-ap.
mutation • DWells>100,000 GPD _ a`& Eta_ D&AMomrr
Non-Water SupplyWell: 0 ft' /0 R. t?nb W� J rtzv .
DMonitoria DRecovery rt. ft.
'Irjeetion Well: '
DAquiforRechaige °GroundwaterRemediation ft. i
•Ma iegri'sd`:Lai '•farklie "tilt r at-g"r ;: == 12 3 x a y xr
11
-- , r..n•rerfa.el. ,...m+levr.!.,7??w.mryrnrvnri'"..--1
C]Aqulfer Test OStortnvvater Drainage . j;
DBxperimeatal Technology ClSubsidence Control it. it. i a
ClQeothemial(Closed Loop) Dinneen t< ... ' .
DGeothermai�ieatitr(r Coo4ngRetam) DOther�ixplain under#31 Remarks) II:" To it.
Orso,N . `."• rcoiar bat lamas trodkt ail ,eta% 1 ,
4..DateWell(s)Completed:i I)3 Well ID# 15ft. 420 n. j raft eke rock
Se.We$Locatiui: 0;
jjr lrt- � a n _ IED -
Pao�ihylOameriYzr> Pao' ID#(if nspplioable) t. It _ ` •' n��rf
3$1(9 oI , �,Ilb rrin ii. ❑Q iq %� 2.16 ft.: fr. DEC 0 5 .2023
•Physical Address,City,and Zip / V ft. ft.
V Vie. f 14 ,%gg61 ,
County Parcel Identification No.(PIN)
i- -u- �_ -. .-« ........ ., .v.a�rraseuss u10Ef ca-.a:
(if veil iiaid;oue farilcne is satiteiont) 22.Certification:
ojAi '
46/10y) /tom]36)).3
6.Is(are)the well(s): I6ermanent or ❑Temporary Si of Codified We Contractor
Byslgntngihtrforei,%hereby care that thc:wslird war(wow)constructed in accordance with
7 Is this x repair to an existing well: Mres or liNo ISA NCeiC WC.0100 or I5.4 AiCdC 02 .0200 Well Construction Standards and that a copy
this is a repa►lr,fill out knows*well construction Information and avian the nature ofthe edits word has been provided to the wwtl mincer.
repair under Ail remarkt section or on the track of this form.
9 _.t6,-.7a.........w m....sarea.....a. as a_.-a1__
a.s titi.... .a,r1• - .ati-:.o=a-a- - o>iz1;s•i ir.-t'... . •
a 1- - -_---* .i .6----'•a.. a,
..zs,..:j�l.ua.,�:i.'ij9.-..-:. ..vun..:i".>t .,...a u-�yyy^' ��. v%ii t.:•1i se'i:�Y^_�lh i;!i_,i`+�l'IavC;:i��'iF+�tit.S.e QL-]ill r_rY�ii�kr���iiy,.�:,u_n,;t i4tFn,
construction,only 1 OW-1 is needed, indicate TOTAL NUMBER of wells (adrt'Sec Over'in Remarks Box).Yottmay also attach adt3'inonal pages if necessary.
dolled: If,,�`�t, 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land:Su face: l d-it+
For multiple waits fist all depths tfd{gerent(example-30200'and 20100') (ft') Submit this GW 1 within 30 days of well completion per the following;
10.Static water level below top of casing: t) ® ( ) 24a. For All Welle: Ocig►nsl fotsa to i Division of Water Resources (DWR),
Ifwatertevet it above casllig use"�:" q^ Information Processing Unit,16I?MSC,Raleigh,NC 27699-1617
12.Well construction method: U ( �'"6 tgf - = V - M1 y
(i e.eager,roam cable,direct push,ate) 24 .For Water Strap and Open-Loop Geothermal Return Wells:Copy to the
••
county environmental health department of the county Acre installed
FOR WATER SUPPLY WELLS ONLY: . 24d.For Water Wells producingover 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gem) I 5- VI
Method of test: V r� Permit Progtam,1611 MSC,Raleigh,NC 27699-1611
13b.DIsinfeedon type: lei Amount: 112 `'
1