GW1-2021-06642_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.3LVell Contractor Information:
14:„WAT'E1t>ZONES x.< ,r
FROM TO DESCR1PT10N
Well Conti-actor Name
Z��ft �� ft ft. ft.
NC Well Contractor Certification Number \I n �i5.zOUTER=CASING"(for:mt7i h case3';wells"OR'•LINER'if a`heable
Morgan Well & Pump, I I V C FROM TO DIAMETER THICKNESS MATERIAL
rt. 01- ft- 61/8 in.
S&21 JPVC
Company Name
16.�TNERCASINGOR:TUBING 'eo
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction ft. ft permits(7.e.VIC,County,State,Yariance,etc.) in.
i
3.Well Use(check well use): ft. ft in.
Water Supply Well M
FROM TO DLAETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) 4PResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18?6RODT
❑hri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
193iSANV/GRAVFXTACK'tf a"`licabfe
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20:D GIOG atfa"chidditional"sb'eets.ifneiiii "
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION,^(col`r,hardness soil/rock e, in size,eta
�f 0 ft. [d ft. fz a V.' r
4.Date Well(s)Completed: 1 Well ID# ft. rqJ"ti t` r�—
)COcation: ft se- ��/ ft
Facility/Owner Name FacilitylD#(ifapplicable) tt. ft 5..
ft F4
a��.� V �.
Physical Address,City,and Zip I X ft ft
OJ�?"� 217IF.MARKS
!I �.
County Parcel Identification No.(PIN) C
I
Inf�rrn3% oi�on
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lonn � ie
g is sufficient)
1 /� 22.Certification:
3� s/�" N 8 k -��1� �3 s WC AA
SlL
4.Is(are)the well(s): Wermanent or ❑Temporary nature of ed 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 tNo 15.4 NCAC 02C.0100 or 15A NCAC 02 .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 fotmn.
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: 2 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J�O (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Qa 200'and 2@1001
(fb 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: V ) 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 toLDWR,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 SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
a i r p ress u re Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: .OJ y'4A`'j 4/_ Amount: Zf O Z
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018