GW1-2021-03215_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
JASO N P O bl.� 14.WATER ZONES
Well Contractor Name O FROM TO I DESCRIPTION
ft. 1
ft. ft.
NC Well Contractor Certification Number Say �5.OUTER CASING tor:muTti-eased'wells OR LINER if a lieable
C29AI 9 it M ,/�'M C O• P` �11`e—G.�, FROM TO� DL1hfETER TtOC[INESS MA���
(� `� U y C Y V [ ft. ft. in.
Company Name _ h �.3, j6.INNER CAS NG ORTUBING eothermaf closed-loop)
2.Well Construction Permit#: E 20 O V I O� �`� FROM TO DIAMETER I THICKNESS MATERIAi.
List all applicable well construction permits(r.e.UIC,County,State, Variance,etc.) ft. ft. in,
3.Well Use(check well use): ft. it. in.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOTS12E THICXNF.SS MATERIAL
Agricultural E)Municipalftbhc ft. ft. in.
Geothermal(Heating/Cooling Supply) Ylidential Water Supply(single) ft. ft. In.
Industrial/Commercial OResidential Water Supply(shared)
1t1..GROUT
Irrl ti0II FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 20
ft. MOE U lig
Monitoring pRecovery tt. ft.
Injection Well: ft. ft.
Aquifer Recharge E]Groundwater Remcdiation 19.SAND/GRAVEL PACK 1f a licable
Aquifer Storage and Recovery ElSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer .20.DRILLING LOG.attach additional:sheets-rf iiecesga
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks 'Rom To DESCRIPTION color hardness.sailtrock fte,grain sim etc
ft. O ft.
4.Date Well(s)Completed: 9 (0�21 Well ID# ft. ft O
Sa.Well Location: ft ft.
BED 90cr—
SHLINE 0MOPMENT ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
16S1 DRNAIM U 215`i� �,�� 1l ft. ft.
Physical Address,City,and Zip ft. ft.
NA S N 21.REMARKS cc
County Parcel Identification No.(PIN) '1JISEM f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification'
N W '4 l 5,12)
6.Is(are)the well(s)dermanent or fOTemporary Signa re of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction h1formation and explain the nature ofthe copy 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i SUBMITTAL INSTRUCTIONS,
9.Total well depth below land surface: too (ft 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
I
10.Static water level below top of casing: Z (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 114 (tn.) 24b.For Iniectlon Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotaryry,,cable,12.Well construction method: construction to the following:
able,,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: A 1636 Mail Service Center,Raleigh,NC 27699-1636
h, V
13a.Yield(gpm) Method of test: V V 24c.For Water Supply&Inlecdon Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: I lb completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016