GW1--05036_Well Construction - GW1_20240828

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WELL CONSTRUCTION RECO _ (GW-11 For Internal Use Only: .
1.Well Contractor nforreatiogt
(r j J 'G( •v_ '14.WATER ZONIS
Well Contr.eaor--N®e FROM TO Daaemlon W
• .3 S 3 ..S !soft �O ft
R R
NC Well Cometor Certification Number
/ y 15.OUTER CASING(for twddi-wed wells OR LINER(Nap Suable)
C(,�jt/ )3 1 Uth e_V S PROM TD rt. rt. Ol DIAALZI T 1 MATUUAL
la
Compemy Naar
G If.INNER CASIn G OR TUBING(Eeotkerm d.l atedao.p)
2.Well Construction Permit 0: 1 1' 9. I e1 1 /MOM Ti) •DLWsill TIEICKTIIIM MATS:MAL
LW d1 appflmble well construction permits(tit.INC Como%l:Sasik Perfonea,silt.) —t ' ft. 1D E0 it n S Xj/Ia. rA 1 rh V(1
3.Well Use(check well use): R ft. to
Water Supply Wen: 17.SCREEN
111OM TO _ DLAMI110t SLOT MU T 1C1Q1S3 MATES
❑Agricultural .OMunicipal/Public • It. It ._ I..
,thermal(Heating/Cooling Supply) ident al Water Supply(single) R, `R In.•
°Indushxl/Commercial identiilWatcr Supply(shared) rs.GRom. •
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D krigatio(t °Wells>100,000 OPD PROM TO MA IMf ACIMMIT MrrlOD&AM
No.-Water Supply Well: 6 R 2 3 R eat '
e./
❑Monitoring °Recovery R ftL �/
• Injection Well: PO,I �t�t,d� [Ln
rt. ft. J /
°Aquifer Recharge °Groundwater Remedialion
niter StorageD.SAND/GRAVVI.PACK(if applicable) •
°A q and Recovery °Salinity Barrio • FROM To MATIRIAL pin-Amara Murano
°Aquifer Test OStormweter Drainage • ft ft.
°Experimental Technology °Subsidence Control ft ft.
• °Geothermal(Closed Loop) °Tracer •2t1.DRILLING LOG(attach addlli..al aheeb if.ecsseary)
°Geothermal(Heating/Cooling Return) °Other(explain under 021 Remark.) InROM TO DESCRIPTION(tear,banLuy wUratlt Ina,p.ia sin,
p� rt. rt.
Date Well(s)Completed: 0 'Z-2 —L1 Wen ID# R .t't .
5a.Well Location: ft. ft.
bbarI"" Cctn.-b R R ,,, 2 S 424 .
Facility/Owner Nam. Psoality BM(if a ,ate) ft. ft.
II t� ,- i l 1 t 54h iti" G rt� _ _ .,.R ft '
Physical Address.City,and zip / ft — ft ,
d 1-1a-Y 11.ItEMAAK3/
Coe '_
0 Parcel Identification No.(PIN) •
5b.Latitude and longitude in degr•ees/mhutes/secoeds or decimal degrees:
(dwell Sold,one laulo.S i1 sufficient) 22 Certification:
i.e:
6 ' 32 ' 2 '. N E/ 1 ' tt 1
W h4tM' r" Y,Z ,zy
f.1s(are)the well(s):)(Permanent or °Temporary Z 9'if O ' 9igature efCdt(Le;f ellCaolndor Data
By signing this fon,,.I hereby cer yry that the walks)war('were)a,,.a•aad in eavniam
7.Is this a repair to an existing well: ❑Yes or/No 15A?VCAC 01 uf C:01 Of'WI SIC.0100 Well ConutructionSuu,dsrd,end then"this Is a repair,fill ova knee wakes well omen ake,Information explain the natters alike ci Ike record has bear Povided Se the wag ou.a.
repair,der 011 reworks section or on the bock of this form.
23.Site diagram o r additional well details:
8.For Ge.probe/DPT or Closed-Loop Geothermal Wells having the same You may use the beds of this page to provide additional well construction
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Rtscarb Box).You may also attach additional pages if Deco
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t)0 .
mltiple wells lin all depths ifd(7aenl R
(example- otd 1(0�1007 � )
For a Submit this GW-1 within 30 days of well completion per the(slimier
10.Static water level below top of
`casingg 24a• For All Went Original form to Division of Water Resoeeecs (D
{(water level a oboe,eashtF;ase'+'CO/. D (a) Information Processing;Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: ! 8 (IA) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(
f•
Program,1636 MSC,Raleigh,NC 27699-1636
12.Welt co jR a .hi estructio■teetkod: l _ A 1 1
(La. rotary.cable,dicnct pub,.s.) 24e For Water Suppl and Open-Loop Geotherioal Return Wells:Copy I
agar. •
coucty environmentai health department of the county where installed
' FOR WATER SUPPLY WELLS ONLY:• -
24d.For Water Wellsdda¢aver 100,000 GPD:Copy to DWR,CCP(
13a.Yield(gpm) I Method of task j ( �ro_d Pound Program,1611 MSC,Ralagh,NC 27699-1611
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13b.Disinfection type: 11-71 4 Amount 1 1) . _