GW1--05065_Well Construction - GW1_20240827

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WELL CONSTRUCTION RECO (GW-11 For Internal Use Only: .
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1.Well Contractor-Informed o•
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" � '); •14.WATER ZONIIS
Well Ca ooloe:Nams FROM TO I1L1C]ttTT10N ne
• ft R
NC well Cootrador cab=Number •
15.OUTER CASING(for multi-eased wells)OR LINER(Rip 6uble)
ILLAArrY)CC/K.. 3 rU-'j-t v$ FROMDIAMETERTo DIAMETER _ THICKNESS MATERIAL
may Nome
re rt. la
16.INNER CASING OR TUNING(geothermal ddd-lwp)
2.Well Construction Permit 11: • PROM TO DIAMETER TR10r1(I3s MATERIAL
List all applkable well construction permits(Le.U1C Comfy,State,Variance,etc) -+I ft 1,7 R 51 e,�/ Ia. ^h •
be
3.Well Use(cheek well use): R. re (I Il .�
Water Supply Well: V.SCREEN
PROM TO DIAMETER I SLOTS6E I THICKNESS I MATE
❑Agricultural ❑ unecipal/Public R R ._ is
°Geothermal(Heating/Cooling Supply) /B Aside ntial Water Supply(single) `
n `n la.•
OIndustriallCommercial °Residcntiel•Water Supply Oland) 13.GROUT
❑Irrigation OWells>100,000GPI) PROM TO MATERIAL IMP IACIMWT METHOD&AD
Non-Water Supply Well: • 0 ft 2 2 ft / a-4 't x c-i
❑Maaitoring ORexx, — /V �{
• Injection Well: • �Y R a p�r I (�1y�� r tx. J
' ' °A uifer RechargeIt ft
/
9OGroru►dwata Remedialion
OAquifer Storage and Recovery °Seluri Barrier D.SAND1GBAVELPACK(-dapplkable)
fy FROM TO MATERIAL Et41ACEHENr aisrHoJ
❑Aquifer Test ❑Stormwater Drainage R• ft.
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°Experimental Technology OSubaidooce Control' ft R
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• °Geothermal(Closed Loop) ❑Tracer '20.DRILLING LOG(attach addltieaal sheets if aecwaq)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under/21 Remarks) PROM2 TO rt. DESCRIPTION(ester,bantams,toll/rock tip;r,,;a the,
4.Date Well(s)Completed: Q -J 2-t'(') Well WI • ft- -It .
Si.WelllLLD on:• 1 ) tr to
.J' VVt ! / n R'
• Fecelity/Owaer Nomad n Facility Rid Cif applieabla) ft ft. r 2 27175
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y-z- ' /v t #w eiLat L v— Z'21 -,.I . It
Physical City,and Zip ft. ft
I - 21.REMARKS/—
County Parcel Idcntiicatim No.(PIN) _
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well held,one let/long is sufficient)
22.Ccrllti
d7 94.74;44.
6.Is(are)the well(,) PJPerenanee: or °Temporary �• Si I Signature _ C ' e6l Ca��� b Datteo S Zl
���lll
`�// By signing this rm.I hereby cat that the wells)was(were)constructed in aecordan
7.Is this a repair to an existing well: ❑Yea or/No IS-t M 4C 02C:oita or'IJJI his.4C 02C.0200 IraCvnstrucnon Standard'and that
If this is a repair,fill ou,bm cvvn
to, well ucnon Atfornranon explain the nature.erf the red*word has bee,prm1ded to the well alma:
'repair under 1121 renrants section or on the back"'tills form.
23.Site diagram or additional well details:
d.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the arme You may use•the beck of this page to provide additional well cooshuction
construction,only 1 GW-1 is needed Indicate TOTAL t'UMBER of wells (add'Soo Ova'in Reroarks Box).You may also attach additional pages if ne ce
drilled:
/ r 24.SUBMITTAL BYu3T•RUCTIONS ,
7.Total well depth below land surface: • £0 AO For multiple wells list all depths I/dtferent(example-3®200'and 28J00') go
Fin- Submit this GW-1 within 30 days of well completion
p per the fallowing
10.Static water level below top of casing: .2_6 (a) 24a. For All Wells: Original form to Division of Water Resources
lftroterlerd G above carters ius'+ ,./� Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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II.Borehole diameter. ��//// on.) 24b.For Injection Wells:
Copy to•
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Program,1636 MSC,Raleigh,NC 2 6 9-1163 Underground Injection Centro(
12.Well construction method: a - a-.n .- A I r
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Ct a•auger,rotvx cable,d:xtpoab eta.)
t // �� 24a For Water Supply and Open-Loop Geotbenaal Return Wells:Copy t
• county environmental health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY: . -
24d.For Water Well roddrlo over 100,000 GPI:
13a.Yield(gpm) _ Method of teak •.Air Pexmut Program, hl l MSC Ralagh,N 276C 99 1611 COS'to DWR,CCP(
t,
13b.Disinfection type: r' Agustin 1 0 k✓