GW1-2021-06675_Well Construction - GW1_20211007

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
ontractor In o m tion: 4 o
FROMWATER.,ZONES _.
Well Co' r Name TO DESCRIPTION
ft. ft t
ft
NC Well Contractor Certification Number (��CcC X,On +15;OiTlER CASINGt fo"r"iintilh caied:wells`OR LMR'[f,"a- hcabl6 '
Morgan Well & Pump, IN 'f��= ��'otiN J��J EOM O DLOSTER T)3ICIINESS MATERIAL
ft. ft. 6 1/8 i" Sdr21 PVC
Company Name ;16 R CAS G`ORTUBING."eoflrermal;eldsed loo
I FROM TO DIAMETER THICKNESS N MATERIAL
2.Well Construction Permit#: O
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROM�ErTO x{' DL4METER ~SLOT SIZE THICKNESS • MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft ft in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18QUI r x _
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f[ 20 ft bentonite poured
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
r19 SAND/GRAVERTACK'[fa'Ikatile) s.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology El Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer '20c;DRUA NGLOG'attaeti add[ttonal"sheets:ifriecess `; _:x, "t;:;"
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTI (co or,hardness soil rock a ram size,etc.)
t
4.Date Well(s)Completed:C�-1� Well ID# R. Rft
TT ft.
5 Well Location-
ft.
Facility/Ow erName Facility ID#(ifapplicable) ft.
ft.
sical Address,City,and Zip ft. ft
21'12E1VIARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one I t/long is sufficient)N , �� W 22.Certification:
6.Is(are)the weU(s): fFermanent or ❑Temporary Si e of ertified W Tractor a[e
io nin th form,1 hereby certify that the well(s)was(were)constructed in accordance udth
7.Is this a repair to an existing well: ❑Yes or ONO 15A NCA C.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 farm.
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: /���J'� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3�-' (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-�200'and 2@100)
71 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 to'DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 2.699-1636
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
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection ty Amount: IZ Z_
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018