GW1-2021-06637_Well Construction - GW1_20211007

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1.
WELL CONSTRUCTION RECORD (GW- -D For Internal Use Only: I
1.Well Contractor Information:
TINla:_wAz>lilzoNEs ;�Z11-
Well Contractor Name �,. r,;, `�1 OM TO DESCRIPTION
ft. rt. �
NC Well Contractor Certification Number �01�3
�� �J OUTER CASING'(foc.:mu�h cased°:iveIls;ORLIlHERi if'a livable)' r
Morgan Well & Pump' I N C FRO TO DIAMETER ( THICIOVESS MATERIAL Company Name rt. 6-'L ft 6 1/8 j t° sdr21 PVC
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J( 161aIIVER CASING OR':TUB]NG`'eothermalclosed loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits i.e.UIC,County, ft. ft in.
pp p (' ry,State, Valiance,etc.)
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO ,ft DIAMETER yr SLOT SIZE g THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) 4*Residential Water Supply(single) ft. tt. �•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18_'GROUT =r':
❑hri ation ❑Wells>100,000 GPD 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
:19.'SANWGRAVEL PACK-rfa 'licalile
❑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.=DRILLINGLOG ittach-:additio'nah'sbeets.ifnecess ?;_ ,5_
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock tMe,Nn size,etc
0 ft. v ft. 74
4.Date Well(s)Completed: —1-7-1 Well ID# v f` e► ft N&M b�
5a.Well Location:
I"I c tie:l Lh U-C. so ft• " ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
/yy �1Git/e�� t✓n ,r-�ao��l�L ft. tG
Physical Address,City,and Zip ft. ft
•21:=REl1IARKS.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(�el�id��ng is sufficient) � � � W 22.Certification: —
(b7 b' ` Z
6.Is(are)the well(s): #Permanent or ❑Temporary Signature of Certified 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 *No 15A NCAC 01C.0100 or-ISA 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 GWIi needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:' �� NO 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 if different(example-3Q200'and 2[@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: /6" (ff) 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Q' airpressure Permit Program,1611 MSC,Raleigh,NC 27699-1-6 1
13a.Yield(gpm) � O Method of test: l
L r
13b.Disinfection type: C?A�� Amount: V oluf
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources` Revised 6-6-2018