GW1--06407_Well Construction - GW1_20231009

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WELL CONSTRUCTION RECO - (GW-11 For Internal Use Only: .
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1.Well Controetor•Information: •
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, •14.go li;.;ATER ZONES . I I Well CO.,...r.,,•,.;.; ','..0 '4". ""
DESCRIPTION
3 5 5 ..c-
• • 300 ft.• CA)0 ft. I I
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• NC Well Contractor Certification Number ft..1
15.OUTER CASING((or mold-cased wells)OR LINER(i(ap lieable) •r.A.A.Ai-ry-1 aoVad 0/10.- • FROM I TO I !HAMMER. • I THICICNESS
ft.
ft. ' II i In.
• COmpany Name •
16../NNER CASINO OR TUBING(Kee titer:nal ciaed-loori) --
2.Well Construction Permit#: ..?0 2-1.-.•o 1 L q--/ .
FROM TO DIAMETER THICICNESS MATERIAL
List all applicable well construction pemzfts ge.VIC County,State.Variance.eta) -I-1 ' i 5it) ". . , IA( in. rhir A.: p
3.Well Use(check well use): • ft. ft. - . • .
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Water Supply Well: . • , .17.SCREEN
• °Agricultural OMtmicipal/Public '
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
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OGeothezmal(Heating/Cooling Supply) 41sidential Water Supply(single) ft . ft . in.
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0Industrial/Commercial . OResidentialWater Supply(sharcd) 18.GROUT
°Irrigation OWells>100,000 GPI) FROM TO MAT IA - -'-EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: '
fr -C)-ft--Z 3 f.t. Ne4 i-_-___._._IM---i---1-4;-i:t-'':;'-'
• °Monitoring °Recovery L-- ----It.--.------
ft' ?or i-ii"
-P"."(44
Injection Well: •
.. .-._ '.' °Aquifer Recharge - - • OGroundwater Remediation '
19.SAND/GRAVEL PACK Of applicable) • .
°Aquifer Storage and Recovery OSalinity Barrier . FROM TO MATERIAL EMPIACEMENTMETROD
ClAquifer Test OStormwater Drainage 1 ft ft.
•°Experimental Technology CISubsidence Control • - ft. ft.
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• Geothermal(Closed Loop) °Tracer. 20.DRILLING LOG(attach additional sheets if necessary)
. DESCRIPTION(color.hardness,soil/rock type.grain size.ete.)
°Geothermal aleating/Cooling Return) °Other(explain under FROM TO#21 Remarks) - ft.
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4.Date Well(s)Completed: 9-1(”..43 . Well 1:0# .
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• NWell Locationki . . ..,. it • ft. IL : • . . .
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a4-.-e„. f tvi b..e i 1 1 1.
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• Facility/Owner Name . Facility lD#(if applicable) ' ft ft 1; .•-:-- .- 1,,,1 g--; -
c13 2 3 1-1-P4 s4 a ch ReA 711 t4 yip.,, Pic,
. ...Physical Address,City,and Zip ft. _ • ft ! OCT 0 9 2023
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21.REMARKS! ,- . . •
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• • i. I trqc,r,r,14.':?.n nD timi, • . ' ,.
County 'C-2.; Patel Idenfificadon No.
• . 5b.Latitude and I gitude in degrees/minutes/seconds or decimal degrees:
WTI field,one lat/long is sufficient)
22.Certificallon: .. . ' . •
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6.Is(are)the well(s): e‘manent or ClTemporary /6,76, Si..-. Well C tractor Date
By signing this/aim. hereby certij,that thewell(r)was(were)canto-grated in accordance with
- 7.Is this a repair to an existing well: °Yes or. No •--:-c. - 114 NC4C 02C:0100 or75ANCIC,02C.0200 Well Construction Standards and that a spy
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 wider 021 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 •
(add'See Ova'in Raziarics Box).You may also attach additional pages if necessary. •.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:- . -
24.SUBMITTAL INSTRUCTIONS •
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9.Total well depth below land surface: 0 el a •
(it) Submit this GW-1 within 30. days of well completion per the following:
For multiple wells list all depths if thyferau(exampk-3@200'and 2(§100) •
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• - Static water level below top of‘casing: / 0 0',.. . (ft) 242. For All Wells: Original fi orm to DiViSion of Water' resources (DWR).. ,
Infozmation Proce.ssing Unit,1617 MSC,Raleigh,NC 27699-1617 •
Ifwater level is above casing:use"+"!.
11.Borehole diameter: Lot I lri- .011.) • - 24b.For Injection Wells:Copy,to DWR,Underground Injection Control(RTC)
Program.1636 MSC,Raleigh,NC 27699-1636
.. ,12.Well construction metho.d: P D 4-.0 Pi - Aloe*" 24c.For Water Supply and Open:Loop Geothermal Return Wells:Copy to the •
(i.e.auger,rotary,cable,direct push,etc.)
county environmental health department of the county where installed
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• FOR WATER SUPPLY WELLS ONLY: . • • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
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13a.Yield(gpm) •I . Method of test ak"--- • Permit Program,1611 MSC,Raleigh,NC 27699-1611 •
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13b.Disinfection type: . FA-1\A Arno. - I -2.„ h.- • 1
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Form OW-1 I CI • North Carolin;lieparnnent ofEnvironmental Quality-Division ofWater Resourees t Revised 6-6-20.18. „
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