GW1--04171_Well Construction - GW1_20240717

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WELL CONSTRUCTION RECO (GW=1) For Internal Use Only:
1.Well Contrecter.Iafon■etion: •
��t 4 •14.WATER ZONES
Weil Contractor �" )ROM r TO nasaumrON
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R n.
NC Well Cre tractor Catiftmtioa Number
15.OUTIR CASING(for aruld-used was OR LINER tlf.p Ruble)
5 Y'Uidh
,�V 5 IIOM R •To DL4Mrril _ Tale7QfLQ MATIaIAL
y Name I
I�f l(N�ia v f� [G f.INCILR CASING OR TUNING(geothermal dad-bsp)
•2.Well Construction Permit�: 7 PROM TO .DfMrsrrsR T>Daerraa i�fATlalAl,
»off applicable well construction peredts(La,flit~County.S vim err) _f`' / R .5•5 n, 5776K I` �[ ►,i_.
3.Well Use(check well use): ft. R. 1a.
Water Supply Well: • j7.8CREEN
• OAgricultmal O antic MAI TO DIAMETrtt Ilmafrs T
Cntras IATtuuAl,
'p`l/Pubiic IL1ha.
❑Geothermal(Heating/Cooling Supply) idontial Water Supply(single)
olndustria Commercial 0 idential'Water Supply(shoed)
la.GROUT
OIrrigatiolr °Wells>100,00(1 OPD MOM TO M_A� latrlACrMINT METHOD k AMOt1N1
Non-Water Supply Well: 0 ft. 23 n. Neck - M, -e t
g °Retw.«y " °i VoY 1:2h d l.Lr,•past
0 onitorin a 1
Injectioncedto Well:
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ttiferltedier rt. n-
❑A
q Recharge °Groundwater Remedialion
15.SAND/GRAVEL PACK(if applicable) • •
°Aquifer Storage and Recove
ry °Salinity Barrier IRON TO MATERIAL DMl1AC MINTMrIBoD
❑Aquifer Test OStormwateDrainage fit. n,
°Experimental Technology °Subsidence Control ' _ ft n.
• °Geothermal(Closed Loop) °Tracer '20.DRILLING LOG Ltt,eh additional sheen if necessary)
OOeottaermal(Heating/Cooling Return) ❑Other(explain under i121 Remarks) ft,
TO DISCRIITIQN(ester,hard■es.,ssaheek tyre,pain she,etc)
rt n.
4.Date Wens)Completed: 7--3- 2-I well IDg • ft .ri• •
5a.Well Location: rt. 1t. •
NIaf-#►zw G . I-> ft. n
• Facility/Owner Naar Fatality II 0(if applicable) ft. ft. 1
CDUil
g4 .) - -.It.
Physical Addre.�sty.and Zip ( ft. n' • InEt3:r, • �,UPIn. U.', .ow
SU rk,•, 21.RalKARx9[ -
CewlY Parcel Identification No.(PIN) _ • •
5b.Latitude and longitude in degree e/mlautes/seco■ds or decimal degrees:
(if well 5eld,one let/long y sufficient)
22.Ccrtific Eon:
36 ' i' '�c'• N got ./ ' S w Carr„,...) N' !?e h��,�
6.Is(are)the wen(s): {hpermanent or OTemporery3 Siauanre �y,- 6,4 7 -3.- Z l�
7.Is this a repair to am existing well: ❑Xea or Br+ldmopthisfo^µ)haibrcert�rhatthewell(r)woe(were)co,4n-eccedae.aond.,<swic
IftI s lea No ISAIVC'.AC 02C:0100 a'7111 R eeC 01C.0]00 wig Cpmftw Aron Sgsdarelr Mein thin a uP
repair,fill out,b,ern well cnnuhunion this
ex lain the nature grthe of Ins raomdhas been prodded to the well cower•
'repair under HI remark:'triton or on the back of this form.
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 23.Site diagram
use the aback or h Additional well details:n
You mpug provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See OvaYou'in Rehcarb Box).
drilled: we may also attach additional pages if necessary.
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: •50
(fit)
For multiple wells let all depths/fellA•ovum(e„serple-30200'and l(a w) Submit this GW-1'within 30 days of well completion per the following:
10.Static water level below top of casing: 8b (R) 24a. For All Wells: Original form to Division of Water Resources
limner level I,above cash%luse-+- ` / Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 • � �
11.Borehole diameter: • /Vr / ) 24b.For I.Jectlon Wells:Copy to D
Program,1636 MSC,Raleigh, �'Underground Injection Control(RJC)
12.Welt construction method: Cr"R {a-Pi ._ NC 27699-1636
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• Oa.auger.nasty,cable,direct push,eta.) l( 1 Y" 24c.For Water Su Lu�nd O ca-Los Geothermal Rehr Wells:Copy to the
• FOR WATER SUPPLY county environmentalhc, apartmeart me county«'ELLS ONLY:
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24d.For Water Wellt producing over 100000 Gni:Copy to DWR CCPCUA
13a.Yield(gpm) S D Method of tat j )' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: / 14- 76 Amount: X N/