GW1-2021-02381_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.WeV Contractor Infor tion: v,4
VTIV W �
14..WATERZONES':= .' `.:'. .:: :... ... ..
Well Contractor Name *' ., 1 FROM TO DESCRIPTION
lft Z ft
,r0� ft ft
Morgan
NC Well nWell & Pumptractor CertificationN lncumber \��Jj`�`aoL 2� 0 FR OUTER C OING.(for m DIAMETER )I THICKNESS a li 1T
+t ft ft 61/6l in' sdr21 pvc
Company Name F .� FROM
✓ r 16:'INNERGASING OR.TIIBING'-'eoth'ertnsl'closed-loo .'
2.Well Construction Permit#: 1 FROM To DIAMETER THICKNESS MA'rR.Rre r.
List all applicable well construction permits(.e.WC,County,State,Variance,etc) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: FROME TO DIAMETER I SLOT SIZE THICKNESS �MATERTAL
Agricultural Municipal/Public ft ft in.!
il Geothermal(Heating/Cooling Supply) EI Residential Water Supply(single) ft. ft in.
i Industrial/Commercial OResidential Water Supply(shared) -
r18:GROUT..Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT '
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring DRecovery ft. ft.
Injection Well:
ft ft
I Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL'PACK if i `licible
Aquifer Storage and Recovery DSadnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test [3Stormwater Drainage ft. ft
J Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) Tracer Zb.pRILLING..LOG'{attidi'sdditioasl sheets:if
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocktype, rain size,etc)
O ft O ft JLeJ t;.
4.Date Well(s)Completed: b Well ID# 1 p ft -IQ ft ,:v n ;
SR.Well Location: 3U ft. 7v ft. 94"d s 1-
S� LS -7 6 ftIt 110 ft
Farcility/Owner a /'Facility ID#(iff applicable) ft ft
6q!0 ocko Re— 1.,. %r 1\4/1/JS�u�'S ft ft
Physical Address,City,and Zip ft ft
'12
:.:.,
- - -
County I Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) c, 22. cation: i N — d O. W �U�►cr '� �Z,`
6.Is(are)the well(s)In Permanent or Temporary Siygnature o ell Contractor Date
By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: C]Yes or JI No with 15ANCAC 01C.0100 or 15.4 NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well ow»er.
repair under 421 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 site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: IIz SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Y� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100D construction to the following:
10.Static water level below top of casing: �G (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
.�/ above, also submit one copy of this;form within 30 days of completion of well
12.Well construction method: i/— construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
56 air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: g
the address(es) above, also submit,lone copy of this form within 30 days of
13b.Disinfection type: C4 a�u r Amount: - completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Enviroamental Quality-Division of Water Resources Revised 2-22-2016