GW1-2021-06643_Well Construction - GW1_20211007

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.VfNI gContractor Infprtltajtion:
t 14;WATER•:ZONES E.':�. f _,�,.z -:�: .... ..,-;<� ,.. .-.
FROM TO DESCRIPTION
Well Co racer NT�e� „^ 4
1 ft. ft.
NC Well Contractor Certification Number 15 OUTER EASING':fo%mph cased;weIls`OR'LIlVER'tf—li6ible't ?.
Morgan Well & Pumps I N C FROM TO DIAMETER THICKNESS MATERIAL
41 it. -7Z rt. 16 1/8 f to Sdr21 JPVC
Company Name a.
�f� 16 INNER:CASING_OR*TUBING`'e"o`thermal(closed loo _
2.Well Construction Permit#:� c FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft rn•
3.Well Use(check well use): ft. ft. in.
I 11"SCREEN
Water Su
PP Y Well FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothenmal(Heating/Cooling Supply) yBResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) _a18 GROIIT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL ENLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 it bentonite poured
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation _
<. K AND/GRAVELYACK`da"livable "
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ENLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control tt. ft
❑Geothermal(Closed Loop) ❑Tracer 21;vl) LLING'LOG attach'`additional-stieets'ifnecess ,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock ram size,etc
4.Date Well(s)Completed: i`s�2 Well ID#
Sa.Well Location:��y� 36 ft. cc rL QtJ S
ft ft
Facility/Owner Name / Facility ID#(if applicable)
l yo3 �y rse� � ft. ft PF w V ..-
Phy ''y_fl1 Address,City,and Zip /2 Q .21.RFMft ft
l �/+Go�h ARKC _
County Parcel Identification No.(PIN) Y c U Unl�
Irt$UII".31"9 't � n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "I 0
(if well field,
one lat/long is sufficient) G� 22.Cer' c tin:
1S %✓O NO N 0 • ���2� I W
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature of red Well Contrecto Date
By signing thisform,I hereby certify iharAl
ell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or (!]No 15A 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 421 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 do provide additional well construction info
construction,only 1 GW�.js needed. Indicate TOTAL NUMBER of wells
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:' ,(i 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 ifdifferent(example-3Q200'mrd 2Q100� 1
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (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 toy DWR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary24c.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
�s air 1 ress u re Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: p
13b.Disinfection type: aa YK it-)W Amount: w Z
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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