GW1--02492_Well Construction - GW1_20240422

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.We 1 'ontrac or Information: a
/ 'i J / Eall�/Qb�rf1r�)I/ I ii.�1WATERR ZONES/ 44'A I FROM TO -- 1 DESCRIPTION
Welt ContractorNamc p t
A!fc.35 L I l%ft. f T,5 ft. ` L/. ldy"
it. rt. I
NC Welt Contractor Certification Number i5.OUTER CASING(far mufti-trased wells)OR LINER(if applicable)
MILLER WELL DRILLING FROM TO I DIAMETER I THICKNESS MATERIAL - _
Company Name ft.
C} fr. CO in. f l �r
I�% -= 1 16.INNER CASING( OR TUBING(geothermall closed-loop) `__
2.Well Construction Permit#: FR FROdi TO DIAMETER THICKNESS MATERIAL
. List all applicable well construction permits(i.e.GIC.County.Slate.Variance.etc.) it. ft, tn,
3.Well Use(check well use): fr. ft, in.
i 17.SCREEN i_
Water Supply Well: FROM I '1.O DIAMETER SLOT SIM.E I THICKNESS MATERIAL.
❑Agricultural f=Municipal/Public I ft. I ft. in.` I •
❑Geothermal(HeatingiCooling Supply) 2dential Water Supply(single) ft"
I fr. is
❑IndustrialCommercial ❑Residential Water Supply(shared) IR.GROUT I
❑irrigation Wells 1130.000 GPD FROM. I TO I MATERIAL EMPLACEMENT:METHOD C,UICH.NT I
Non-Water Supply Well: 6 ft. ..3 ft. fVO{i- �t/I 1 Pum w.ci
❑Monitoring ❑Reco+en 3 ft. ft. ..}? t_�/.it� J9O;� _r/
Injection Well: � - "
ft. ft. .
❑Aquifer Recharge Groundwater Remediation
19.SANDIGRAVEI.PACK(if applicable)
❑Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL FMPI.AC'E.\TF.NT METHOD
❑Aquifer Test ❑StontiwaterDtainage ft. ft.
❑Experimental Technology OSubsidence Control It. ft.
❑Geothermal(Closed Loop) Tracer 20.DRILLING LOG!attach additional sheets if necessary)
❑Geothermal(bleating/Cooling Return) Other(explain under;t'1 Remarks) FROM TO DESCRIPTION(color.hardness miPrnck t}ne.grain size.etc.) _�
C) ft. (�i fr. 7,1..v. - Q Ira-?.JQ..
❑
4.Date Well(s)Completed: I a /2[f Well I11 70 ft. )ft. jt! I
5a.Well Loo�cation: CiAf
ft. rt.(,[10� i.--h�U SE t ft. fr. �.-4 h......�.' .i �j I...LI
Fac:lit•:'Owner Name Facility IDa(if'a applicable)
ft. ft.
Alr L �P/P APR22 ?OM
- / 7 5�ina5 �1 gzof-,.�j 602L ft. ft. .
Physical Address.City.and Zip LI ft, ft. I irtO y,..0 Prr:,^,.f rbiv;i V t>i
21.REMARKS f �+3 by
��rry
County 1 Parcel(dentiflcaijsiii Na. PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f
lit'v:e11 field,one fat/long IS sufficient; 72 j 1.(I ,�)
,�" v .Czrti�calion/�) !� f .''•
� G� �•'C� N r'1''5 V Lo 2b: .5 C-7 W 417 . `]I l i •• -- 12- /-4
�-
6_is are the wells _ erma sent or ❑Tea ovary .. . ,.... •
Signtaure ofCeriilied Well Contractor Date ' '
Ill•signing this 1brn:,I herehr certiti•that die wc•/Its!was here/constructed in accordance Wig:
7.is this a repair to an existing well: ❑Yes or ¢fin rya:etaC 0?C.nip0 or 15•1•;Ci1C 02c:.021)0 Well Construction Stim:Lirisk and thus n sops.
Phis is a repair.fill out Anown sell cottslruelion inlbrniatioir and explain the nature oldie n/this record has been provided ro Inc nc•1!owner. .
repair under ti11 remarks section or on the hack of this Jinni.
23.Site diagram or additional well details:
II.For Geoprohe/DPT or Closed-Loop Geothermal Wells buying the same You may use the hack of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMi3ER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: t/s 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .2•6 J (ft.)
For multiple wells list all depths ifdifei•en!(example-3(p. ii0'and.faiMtPj Submit this(zit'-1 within 30 days of well completion per the following:
10.Static water ievel below top of casing: *re ,2, (ft.) 2.3a. For All Wells: Original form to Division of Rater Resut'rc•e.s (DWR).
Information Processing Unit.1617 NISC,Raleigh.NC 27699-1611
11.Borehole diameter: l9 (in.) 24b.For Injection Wells:ConvIto DWR.Underground Injection Control(ICC•) ,
Program_1636 MSC,Raleigh.NC 27699-1636
12.Well construction method: •0 n 1 it 1 es17Ar VI
24c.For Water Supplyand Open-Loop oop Geothermal Return Wells:Copy to the
(i.e.auger.rotary.cabs;,direct hush,eta) county environmental health depandtent attic county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR.CCPCUA
j/ Permit Program.161 1 MSC.Raleigh.NC 27699-161 1
i3a.field(gpm) t Method of test:
r• ,, ,P
13b.Disinfection type: i"i t R Amount: '(
Form GSV-I North Catalina Department a!'Lin•:irunmetnal Quad ty,Division of Water Resoures s Revised 6O•_01 R ,