GW1-2021-02611_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1 Well Contractor �Information: yam,,� e'�'•�" .i4 waTER zolvEs. , �, a. ��.�,. K�_:
J�� FRO TO r ~DESCRIPTION
Well Contractor Name f� g 6� t 7 ft.
e ft
"')
NC Well Contractor CertificationNumber '^C1;,3iiGI1t it "r
fitly \'py� Cc1Q 15:OUTER`.C_ASING for.mu7h-cased welts ORSINER(if;a 'licatile
Morgan Well & Pumps I N FROM TO DIAMETER TffiCKNESS MATERIAL
Company Name 04- ft 61/8 in- sdr21 PVC
9RWIN- 003�� --16.'IDW R CASITIG;OR TUBING enfhermal'dloseadoo ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft t°'
3.Well Use(check well use): ft. ft. in.
Water Supply Well: tl �FROM DIAMETER-i..SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) &esidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18':GROUT -
❑hri ation ❑Wells>100,000 GPD FROM TO n_ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fc• 20 fc• bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19 SAND7GRAVEL"P�iCIC:da""lieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer :20 DRILIINGl'OG attach'additi6ual'sheets:ifnecess
FROM TO DESCRIPTION color,hardness soil/rock e, ram size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Oft. 'Lp ft. T);r
4.Date Well(s)Completed:O—16 2k Well m# Zed A.^ �`�-�►
Sa.Well Location:
M.C4Ctt� 'r4SSA440 'Ql r�••��-e.
Facility/Owner Name }.Facility ID##(if applicable) ft. ft.
ft. ft.
Physical Address,City,and Zip L� ft. ft.
��rI CA(tip C) 1�� -.21"RF.MARKC -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long—iis sufficient)N Q q 22.Cer'cation:
/ 42 �"V I 'O �317(�0 W
6.Is(are)the well(s): 4VPermanent or ❑Temporary Signature of Certifie ell Co❑tractor 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 ♦No 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 I GW- 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: qz C.) (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@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 0 (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)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: RCta'1•1•��
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 Ever 100,"0 GPD: Copy to DWR,CCPCUA
3 air pressure Permit Program,1611 MSC,Raleigh,NC27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type:� n"1 r Amount: V'L
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources: Revised 6-6-2018