GW1-2021-05520_Well Construction - GW1_20210901

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
K 1
1.Well Contractor Information:
.:14',WATERZONES .n
Well Co eto Name `� r` FROM TO '{DESCRIPTION
J✓' �r ,-�t f f �:)ll��� `ill Il
NC Well Contractor Certification Number
INC
15::.OUTER;CASING-(foFhi—u76 ca`s6d-wells)-OR-LINER if�a'-Morgan Well & Pump, I N C FROM TO DIAMETER THICIQVESS MATERIAL
4, ft. ft. 61/8 �in Sdr21 JPVC
Company Name
j,j,(p!1T"�j ' 16;INNER C" ING.ORTUBING(e6 ePmaPclosed,loo _
2.Well Construction Permit#: 4 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. - in.
3.Well Use(check well use): ft. tt. in.
Water Sti 'ly Well: 17S,SCREEN
'pp
FROM TO DIAMETER SLOT S17-E THICKNESS MATERIAL
❑Agricultural ❑Municipa]/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑h-i ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- bentonite poured
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation _
19:SAND/GRAVEL'iEACK tf a."likatile ..
El Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothenmal(Closed Loop) ❑Tracer 20;:DRiLLING-LOG`attakh1ddttioriil;iheet's.ifuecess
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,Hardness,soil/rocke, rem shetyp etc)
v
/"� ft ft. is . � 6
9
4.Date Well(s)Completed Well ID# Sft.
We Location-Well �D it. X
As a Rrir'�y
Facility/Owner Name p Facility ID#(if apAplgiccaa'ble)��p ft. D C'L II
PhySiGa�]Address,City,and Zip ft ft
=21`RE111ARKS --
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/llonng is sufficient) Qr�, 22.C • cation:
s��� �� N 9a✓���j�.��p W Y
6.Is(are)the well(s): IftPermanent or ❑Temporary
rtified Well Contractor UXEeriru.�Ih.eform,1 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 02C.0100 or 15A NCAC 02C10200 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,pnj'y�GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:' `y��� 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 di�'erent(example-3Q200'and 2@100)
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
•• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If wnrer level is above casing,use op
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
i
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
I
a+&),�13b.Disinfection typej r Amount: 2—�
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018