GW1-2021-07893_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: M
i
I.Well Contractor WTag0
t
14 WATERZONES
Well Co tra or ame FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number �.
I/'+ 1H'O,UTER'GASING:(for.mb7h cased:ivell`s-ORL-INER if.ii
Morgan Well & Pump, I I V C FROM TO DIAMETER THICKNESS MATERIAL
l ft. �C) tt 61/8 i" sdr21 PVC
Company Name S��`�
16 INNER'=CASING'OR;TUBING 'eothermaldosed400
2.Well Construction Permit#: FROM I TO I DIAMETER TH1cIaaEss N MATERAAI.
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 TO DIAMETER`$ SLOT SIZE THICKNESS +MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) IfResidential Water Supply(single) ft. ft. i"•
❑Industrial/Commercial ❑Residential Water Supply(shared) -
18i'GROUT
❑hn ation []Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 it bentonite poured
❑Monitoring ❑Recovery
Injection Well: g, ft
❑Aquifer Recharge ❑Groundwater Remediation
'19 SAKI)/GRAVI:rI,PACK'If a `lic'able
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Cl Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer '20iDRIISSNG'I O.G,attach'addttioual"sheets_if:iiecess -' _
FROM TO DESCIMTI N color,hardness soil/rock e, ram sue,etc-).
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) � Se et +
4.Date Well(s)Completed: Well ID# ft. ft.
5a.1Well Location: �� ft. ft.
ft. rxlk—
ZOO rc.
Facility/ net Name F li ID# if a licable
,91qsical Addre ity,and Zip ft ft
2VREMARKS
,� nr•n4 step �1.�7Z1 Y
ounty Parcel Identification No.(PIN) '' '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,o e lat/long is sufficient) �(f ( *NO2C.0100
6.Is(are)the well(s):'®Permanent or ❑Temporary ed Well Contractor Datek
,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an eldsting well: ❑Yes or r@No or 15.4 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 tinder#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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:' 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 ifdifferent(example-3Q200'and 2Q100�
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)
12.Well construction method: Rotary
Program,1636 MSC,Raleigh,NC 27699-1636
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 Water Wells producing 100,000 GPD100,000 GPD: Copy to DWR,CCPCUA
a I r ress u re Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: p
13b.Disinfection typeN\t1r' Amount: QZ/
— i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018