GW1--02538_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: •
1.Well Contractor Info// atiion: Airi-wi,
• -Al;il1)/l 1t ®�/-e ' / gCe_., 14:WATER ZONES
• Well Contractor Name PRIM .221Y DESCRIPTION
�G�� //Z ft., /z�ft. r
. - is,p ft.' l'Cali))
ft. t
NC Well Contractor Certification Number, [L/f/.S //ti{j!`I
/0t/./'UM` FROM
TER CASING-(for multi-cased Wells)O :INER(ifap liable)•-•.'A.,
TO DIAMETER THICKNESS MA
Company Name // 0/Zift qg ft 6/g in. '/z- ,//VG
2 2 ((JJ 16 INNER.CASILNG:OR TUBIINGIgeothermal closed-loop);- •: %"' _ . .
2.Well Construction Permit#: 3 - 3 3'2- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constrabtion permits(i.e.UIC,county.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) JrResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) : :• -_
:18.-GROUT:: ::.:=�.; ... .,:' �.. - .:... _..�:•:..,., .. .:.
❑irrigation ❑Wells>100,000GPD . FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge : ❑Groundwater Remediation
19.SAND/GRAVELPACK(if applicable). =
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer •-20.DRILLING LOG(attach additional sheets if necessary)-,':. <, :: --.
❑Other(explain under#21 Remarks) FROM To DESCRIPTION(rotor,hardness,soluroek type grain size.etc.)❑Geothermal(Heating/Cooling Return)
y� Q ft. /5 ft. ,,.,e c tee,
4.Date Well(s)Completed:, "n•-&9 Well ID# .'S it VS it y e/iQL J e. (ca.y�
5a.>Well Location: //�� i - 7 S ft. 77 ft. ,Ifre a -c1„....fi ` j
tzt6uci -Io cb%Me/t rue.. i&€.4.-. 79 ft ,366 e. / I I r - ,A icf'e j- q tc
Facility/Owner Name D� ,/,�_ dl.Facility ID#(if applicable) ft t f
•
7 f'9 tAki. (/lctiJ .Ll `c... !/ 14// ktiCe4ett1 ft ft.
Physical Address,City,and Zip p ft. ft. <�•n" e'.'i I
. d 1
.6110%1 r6 `o 2 'o/ e 27.`REMARICS?• "':;:::;'.:'- -APR 3 LUCIM •
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;;�,;'-7.��,
(if well field,one lat/long is sufficient) 22.Certification:
5% F6. 7t�0 �
P�S N fe•
Z4 W 3-o.-z4
6.Is(are)the well(s): llgPermanent or ❑Temporary Signature of Certified Well Contractor 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 .'No ISA NCAC 02C.0100 or ISA NCAC 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 rennar/s section or on the back of this form. 23.Site diagram or additional well details:
8.For GeoprobelDPT 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
r,
9.Total well depth below land surface: 30 l.J (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)
3*--- fL 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"T"
11.Borehole diameter: 6'ig (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
l Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 1mt O liars/ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) Q 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
13a.Yield(gpm) O Method of test: 11.P•-• Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 11/7-17 Amount:_,FAilifb