GW1-2021-07890_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.We 1 C ntractor Informati n: i
I
,14 WATER<ZONES.... "
Well Contra or N a FROM TO f DESCRIPTION
ft. ft.
ft
N el(Contractor Certification Number A I�+ `15',OUTER,CASING'fo`cmultr-cased-well§`.ORI INER:if a`bcable
Morgan Well & Pumps I I V C FROM T DIAMETER THICKNESS MATERIAL _
tt. ft. 6 1/8 !in- sdr21 PVC
Company Name . o ,,g6:INNEWC` lNG.OR TUBING ""eothermal closbd loo <s e z
2.Well Construction Pe � FROM To DIAMETER THICKNESS MATERIAI,
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft in.
Z
Water Supply Well 17'St REEK v.r > z ..
FROM TO DIAMETER SLOTSIZE I THICKNESS J MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) JOResidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GIYOUT T
❑hri ation ❑Wells>100,000GPD 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 f
19i SAND[GRAVElDPA`CK`if 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
❑Geothennal(Closed Loop) ❑Tracer 20 DRII LING'LOG.attach'a'ddttional'sheets;if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(exp lain under#21 Remarks) FROM TO DESCRIPTION color hardness,soil/rock c e, rain size,et '
0 ft. ft. )'VV I
u I t
4.Date Well(s)Completed: Well ID# a ft. ft
i
5a Well Location: ft. M ft irk
kd
Facility/Owner Name Facility ID#(if applicable) ft. ft r^� y�y j}_ 4 `
i V ft. ft J
cal Address,City,and Zip G {j'{�` LQ� ft. ft.
') l \� 21'RRMARKG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlon^g�is sufficient) (�, -22. tificatio'i�� `/�f
t5 J N _70 . 33 I5 W /✓l
6.Is(are)the well(s): Mermanent or ❑Temporary S' a of Certified Well Contractor Date
y si mg 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 &o 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 fw7n.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �m (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3®200'and 2©100')
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"+•'
6 24b.For Injection Wells:Copy to bWR,Underground Injection Control(IUC)
11.Borehole diameter: p (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rota'Y y
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 Cod
Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type Amount: L7Ki
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018