GW1-2021-00461_Well Construction - GW1_20210210

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jason P Morton
Well Contractor Name FROM TO DESCRIPT(
ft. ft.
2953-A
ft. ft.
NC Well Contractor Certification Number 15..0UTER CASING,for„murh,cased.`wells 0WLINER tf a"' ltcable
Morton Drilling FROM TO DIAMETER THICKNESS I MATERIAL
ft. I. in.
Company Name �/ a16.-1NNER;GASING'OR TUB G, _eot" 6ermah�clo`sed 1 0 _ -
2.Well Construction Permit#: / e 9 3 / FROM I TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits f.e.UIC,County,State, Variance,etc.) ft. m ft. in. (i
3.Well Use(check well use): ft. V ft' in.
Water Supply Well: 17-SCREEN.
FROM TO DIAMETER "SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public t. k. ? in. v L
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) it. R in.
❑lndustrial/Commercial Residential Water Supply(shared) gg GROUT., ,
❑hri ation OWells>100,000 GPD FROM I TO MATERIAL EMPLACEMENJ METHOD&AMOUNT
Non-Water Supply We1L ft. ft. ! J(' Sad L pS
❑Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
`;;+I9:SAND7GRAVEL:PACIG(fa -licatile
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT M THOD
❑Aquifer Test ❑Stormwater Drainage D ft. V ft. S4rP4 JO0 V r-0
❑Experimental Technology OSubsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20:DRI1 LING"LOG. attach idditionalsheets if,necessar,
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) rt. IL
4.Date Well(s)Completed: 2� Well ID#
k.
Sa.Well Location: t.
"1 g&1 L CG-,erriAli« «.
Facility/0 ner Name Facility ID#(if applicable) ft' ft,
Physical Address,City,and Zip ft. I ft.
Carteret 21.:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
field,one lat/long is sufficient). t 22.Certification: /
�7 Y V IU:2 1,06, p N 7b ?s 0 7 W96z� .1 -
6.Is(are)the well(s): ermanent or ❑Temporary rl'i":
ure of Certified Well o ctor Date
ing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or o l SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information an plain the nature of the of this record has been provided to the well owner.
repair under#11 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
(god' ee Over'in Remarks Box).You may also attach additional pages if necessary.
�•■
drilled: 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
`S[1I3�IITTAL INSTRUCTIONS
9.Total well depth below land surface- (ft) gqyyb"24is 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') 6 7 Zv
24a FAr.Alll 011s: Original form to Division of Water Resources (DWR),
if Static water level below top of casing: �7 - (f��rt16fonnation Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
if water level is above casing,use"+" � iT�s r^l`nr i f)tl
11.Borehole diameter: (in.) 24b. For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ,rK�<-► 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
FOR WATER SUPPLY WELLS ONLY: - 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-161 t
13a.Yield(gpm) -0 Method of test:
Z
13b.Disinfection type jP/ Amount:J•0
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018