GW1-2021-01484_Well Construction - GW1_20210429

FmCORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
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Jason P Morton b
Well Contractor Name FROM I TO DESCRIPTION
2953-A rr. f/ (� rr. I A10� K
ft. fi.
NC Well Contractor Certification Number !
i 15.OUTEWCASING'for intilti cased;;wetls'OR�'�LINER if a bcable •�`
Morton Drilling =NG_-0R1'
DIAII ETN.R TffiCKNESS MATERIAL
Company Name
UBING; 'e`othe?trial°closed loo`���„ ,•w '` '' =%
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits ri.e. UIC,County,State, L`ariance,etc.) 11. Q' 11. in, 5CA Ile t/ G
3.Well Use(check well use): ft. s� f z R. in.
Water Supply Well: 11 SCREEN ,
FROM Tvfj DIAMETER SLOT SIZE YTHICKNESS I MATERIAL
❑Agricultural tsidential
OMunicipal/Publi f ft. in.❑Geothermal(Hea[ing/Cooling Supply) sidential Water Supply(single) rt•Olndustrial/Commercial Water Supply(shared) 1$.'GROt1T
❑irri ation O Wells> 100,000 GPD FROM TO f Ji MATERIAL EMPLACEMENT MET,IfOD&AMOUNTt`z
Non-Water Supply Well: 12 rt. —3 ft. 0 1
❑Monitoring ORecovery ft. — fr.
Injection Well:
OAquifer Recharge OGroundwater Remediation
79.SA 91GRAVELPACK;ifa "lieable
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test . OStornwater Drainage ft.
❑Experimental Technology OSubsidence Control
..
OGeothermal(Closed Loop) ❑Tfaeei i 20,.DRIGGI.N010G attacti;dddwo`nat=steels if necessar r- >..;"�., � '`
OGeothettnal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness solltrock type,grain size,etc.
fr. f ft. �.
4.Date Well(s)Completed: —,A � Well ID# 5 ft' �JLa rt. jDta-iG}r Q Y
5a.Well Location: D�LYiOI 1l9�'STj Ft. ft,
)q(- 11j (� t+A1 rt. r��j ft. o C
Facility/Owner Name Facility ID11(if applicable)
fL ft.
Physical Address,City,and Zip /% ft. ft.
�.Carteret 4L REMARKS= .
179
County Parcel Identification No.(YIN) Ing Untt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
nDWR Section
(if welll field,one fat/long is sufficient) 22.Certification:
/ ��-ll
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,,�cam,..
6.is(are)the well(s): �p"ermanent or ❑Temporary azure of Cuntfied Well Contractor Date
��tlll ` Utz signing this jorm,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or t l'a 15A NCRC 02C,0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a copy
/jrhis is a repair,Jill out known well construction itybrmalion an rplain the nature of the of this record has been provided to the we11 owner,
repair under#21 remarks section or our the buck ojthis jorm.
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 i 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 INiSTRUCTIONS
9.Total well depth below land surface: J I (ft.)
Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths ijdgerent(example-3(c�2llll'and 1(t�100')
24a. For All Wells: Original fortn to Division of Water Resources (DWR),
lj water Staticleg
f10. v al is above casing,use water level below top of casing: �- (it.) iriformation Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
at "+"
�� 24b. For Iniection Wells: Copy to DWR, Underground Injection Control(IUC)
t L Borehole diameter: (in.)
Progoraii, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: r\e> 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departtn'lent oC the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
132.Yield(gpm) Method of test: A)R Permit Program, 1611 MSC,Raleigh,NC 27699-1611
1 L7 1
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13b.Disinfection type:�"J1)ORI N� Amount: 1 t v z
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources