GW1-2021-07895_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. olntracto ation:
W
74'rWATER ZONES< r �_
FROM TO DESCRIPTION
Well Contract Na
ft. ft
NC Well Contractor Certification Number - - a
-,AV FROM TO OUTER'CASING(for'mttlh DLAMETEcasedwells;ORI;INER"d;a. hcable t
Morgan Well & Pump, INC R I THICKNESS I MATERTAi.
ft. 61/8 ! in sdr21 PVC
Company Name
<-6.=INNWCASINGOR-JUBING 'eot5ermal`cidsed,loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
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.
Water Supply Well: FROM-REE TO j` DIAMETER �Y�SLOT S17-E` THICKNESS 3 MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) joResidential.Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) g GROiTf,
❑Irri ation ❑Wells>100,000 GPD FROM TO*� MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20 fit bentonite poured
❑Monitoring ❑Recovery ft. fit.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19<.SAlVD/GRAVIIPAC�C`tfa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD y4
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology El Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer ;20I)RILIINGLOG attaib;additional"s7teeLc;ifnecess . 4
❑Geothermal(Heating/Cooling Return)
TO DESCRIPTION(color,hardness soil/rock e, ram size,eta) ❑Other(explain under#21 Remarks) © ft. ft
4.Date Well(s)Completed: Well ID#
5aa Well Location- ��f�iA rp fit. fit.
Facility/Owner Name Facility ID#(if applicable) �✓ ft. !�n,.a ft T q�,+ ',j ✓
hysical Address,City,and lip, ft, ft n 21
?s:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Gj 22.C ication:
N 3 r'Jl1 W <f4' , 7,
6.Is(are)the well(s): &Permanent or ❑Temporary Si ur o ertif, e 1 Contractor Date
igni g t $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 dWo 15A N C 1C.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 at the back of this fo m.
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 Ito 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 if different(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: (fL) 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
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
13b.Disinfection ty e Amount:
i
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018