GW1--05883_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Wellll Contractor formation:
/mot"✓1►I<"✓% Q'l //!/1 i'-n AZ 14.WATER ZONES
Well Contractor NameFROM TO DESCRIPTION
-oj Z,7.>R• ,/�I Qfc
NC Well Contractor Certification Number 7t�
ft.•// LITER CASING(for multi-cased wells)OR LINER(if a ble)
a a 1�1/S `,Je f ,,1/1� FROM TO DIAMETER THICKNESS MATERIAL
Company Name `l`l lI /k i. /e k,ft. /_'�� in. , G 7 0 A/C.
,// 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: l C U/ 7 6 C.)r0 Zi FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County.State.Variance,etc.) ft ft. in.
3.Well Use(check well use): it. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:Agricultural ❑Municipal/Public rt. ft. In.
OGeothermal(Heating/Cooling Supply) pR sidential Water Supply(single) ft, ft, in.
❑IndustriallCommercial ❑Residential Water Supply(shared)
Ig.GROUT
❑Irrigation ❑Wells>100,000 GPD . FROM TO MATERIAL EMP CEMENT METHOD do AMOUNT
Non-Water Supply Well: © ft. �.f� ft. %, _L� rite.1C �j
Gu
OMonitoring ❑Recovery ft. rt. �� /
Injection Well:
uifer Rechargeft. ft.
❑A
q ❑Groundwater Remediation
❑Aquifer Storage and Recovery OSalinityBarrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test, ❑Stormwater Drainage ft• ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DES RIPTION(toter,hardness sowrack type grain size etc.)
j r, 0 R. /5. P-6C ri
4.Date Well(s)Completed: CJ`- ."1��7 Well ID# /-' ft- ft Ve /0..
G.
5a.Well Location: ..t ' ..:10 ft. VO rL /C /��CS�a.01r-1,
Facility/O r Name Facility D#(if applicable) r00 ft. ,.��f. //5c /�r� `
/06 S4.-dc_P �sf f,I ZOtt. , MC)ft. (y)<.,.or;/-t%sl y _
Physical Address,City,and Zip ft. ft S. . A 1
. t j
/i k-C✓s,.Je 1 ell do j,,Q �3' 7/ 7 21.REMARKS
County Parcel Iddentification No.(PIN) l) 1 ,)rP<
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _ , . ' .:'. r ,Jr!
(if well field,one latilong is sufficient) 22.Certification: ,'T;`,..7;,•3._.s
35. /i-/ 19 N �/,C) z,Z `y ZF w r-s ce--�j'..-Z5-1
6.Is(are)the well(s): q?dI manent or ❑TemporarySignature of Certified Well ntractor Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or SKI ISA NCAC 02C.0100 or ISA NOW 02C.0200 Well Construction Standards and that a copy
If this is a repair fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
, repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
' 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
�/ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3�S (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3©200'and 2@100')
t0.Static water level below top of casing: JZ e ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
limier level is above casing.use••+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
•
11.Borehole diameter:
67s/ 24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UC)
(in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ct.�, 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) OO county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
✓
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /d d Method of test: //� '
136.Disinfection type: H T7I Amount: 5p-1,/-s