GW1-2021-06670_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
i
1 tractor Informati
<WATER=ZONESMe
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ntract Name O �,`�\\ FROM TO DESCRIPTION
f\� V rt. ft. I
a4 ZZ pC �?v"�'e �� ft. ft. !
NC Well Contractor Certification Number \O� COS-
, 15 OUTER':CASING:for".miil0-cased:weIIs OR-ISNERi tf-a bcable;i.:'
Morgan Well 8t Pump, I N `� p\'�� FROM T° DLSMETER THICKNESS MATERIAL
ft. b ft 61/8 In sdr21 I PVC
Company Name
:16'INNER`CASING:01(:TUBING"'e"'othertni ii closed'Ioo
2.Well Construction Permit#: FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. fL
3.Well Use(check well use): ft. ft
1 17;SCREEN
Water Su
PP Y Well FROM TO DLAMETER 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) `12esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:'GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO r MATERIA.L 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
>19 SAND/GRAVEL-FACE tf a "livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer :2vi`DRILLIIVGI OG attachhaddtaouali'sheets`d'uecess y _. ..
FROM TO DESC TION col r,hardness sorUrock y e,- m size,etc. `
❑Geothermal(Heating/Cooling etum) ❑Other(explain under#21 Remarks) � ft. ft.
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4.Date Well(s)Completed: ` Well ID# l ft. ft
Ze Location: '50 ft. fL SWY! roL
AA
t. " (AA t e—
Facili / t Nam Facility ID#(if applicable) ft. ft
1�-re-� ( ft. ft.
s,all Address,City,and Zip it ft ft
COa � � ARKC
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fireld,one lgat/long is sufficient) Q C j22.0 leatio'3 -Y -` - N y . J W a
6.Is(are)the well(s): JPermanent or ❑Temporary of Certified Well Contractor Dati
gn g 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 IrNo 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#21 remarks section or on the back of this faro.
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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2©100D
f� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: V (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
I1.Borehole diameter: 6 0 (in.) 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection typ4�4)YlV`'C� Amount: 7 3 cw, d
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018