GW1-2021-02558_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well Conn tractor Information-WV
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Well Contractor Name w FROM TO DESCR1PT10N
ft. z� ft
�2S 1 ��1Z1� ft. ft
NC Well Contractor Certification Number
UN Ka
�,i.1il 1 y 15s`OUTER,CASING:fo%mutt cased"-wells:OR:I-INER if a hcable s ,
Morgan Well & P u m U 11 V a J �i FROM TO DL��TER TffiCKNESS MATERIAL
ft. ft• 61/8 In sdr21 PVC
Company Name Ig�,r-�
s :16INNER;@ASIIVG:ORTUBING, eothermaLclosedloo `_` `' `"_�'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS M TERIAL
List all applicable well construction permits(i.e.UIG County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply
PP Y Well: FROM TO � DIAMETER ' SLOT SIZE THICKNESS _. MATERLAL
❑Agricultural ❑Municipal/Public ft. ft. in.l
❑Geothermal(Heating/Cooling Supply) ;!!Residential Water Supply(single) ft. tit. in.
❑hidustrial/Commercial ❑Residential Water Supply(shared)
❑h11 ation ❑Wells>100,000GPD FROM TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
❑Monitoring ❑Recovery tt. ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
.19:'SAND/GRAVEL PACK tf i""Heable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL Y EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20DRILLIIVG�L`OG Attack'addifion"al sheets.ifnecessa
FROM TO DESCRIPTI N color,hardness,soil/rock e, rain size,eta
❑Geothermal(Heating/Cooling
Return) I❑Other(explain under#21 Remarks) v ft. �y ft. t) t^-
4.Date Well(s)Completed: O �7, Well ID# s ft. ft V1bC3"�
Sa. ell ocation: 1 ft. p ft. �
�L i U eTS �fj ft. j)Oft r,t GYMS
Facility/Owne Name Facility ID#(if applicable) ft. fL
lz (x T4`` ft. ft.
Pbysica Address,City,and Zip {� ft ft
4S)ro ti
Tryy-6l-�JV� 21'R MARKS _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22 r Ifieation:
3 S.37Gs13 N
6.Is(are)the well(s): *Permanent or ❑Temporary SignatukeqSRerrtified Well Contract Date
By signing 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 ANo 15A NCAC 02C.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 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 GWJis 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 diQ"erent(ecample-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: V (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: p (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Kota'I 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,'00 GPD: Copy to DWR,CCPCUA
` a i r pressure
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:13b.Disinfection type:0A41yJd-r n Amount: b 1,
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018