GW1-2021-06635_Well Construction - GW1_20211007

4
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well C ntractor Informati0
_ l
Well Cont tor ante FROM TO r DESCR1PT10N
L ft. ft
77
I ft. ft.
NC Well Contractor Certification Number � ^15 OUTER'CASING`(for`m tt-cased well's:OR LINER`if;a hcable i , zs.a w.
Morgan Well & Pump,
I I V\ C�S'e O(\ FROM ft TO ft DIAMETER to TffiCHIYESS M 9TERIAL
3=f� e��� 61/8 Sdr21 PVC
Company Name �Ot� �Na
�� Q 76'1NNER CASING OR TUBING "eo2herinal,closedloo
2.Well Construction Permit#: FROM TO DIAMETER TfficxivEss
construction
List all applicable well consection permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft m.
I 17:SCRBEN
Water Su
PP Y Well: FROM TO DLAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Pubhc ft ft. in.
❑Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft ft in.
❑Indust ial/Commercial ❑Residential Water Supply(shared) 18 GROUT, ',t
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.'SAND/,GRAVEL PACK Cif a `lieatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING.`L'OG'a"tticb.iddittorialsheets if'uecess "=
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DES TIoly(colgor,hardness soil/rock m ra size,etc.
O ft. 24> ft. A
610
4.Date Well(s)Completed A Well ID# ft.
ft.
Well Location:
Lite;
Facility/Ow r Name Facility ID#(ifapplicable) . rXrttz
/ ft. ft
sicaaAd ss, b ft. ft I
Ph ,and Zip
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,onelat/long is sufficient) �r C� 22.Certification:
35.5)21/ �N — O •�/0s W
6.Is(are)the well(s): APermanent or ❑Temporary *By "
Certified Well Contractor
is form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or fiNo ISA NCAC 02C.0100 or 15A 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 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 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
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3Q200'and 2@100�
I
MM 24a. For All Wells: Original forin to Division of Water Resources (DWR),
10.Static water level below top of casing: tW (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
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 SUPP WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: /
13b.Disinfection typ Amount: f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources'. Revised 6-6-2018