GW1-2021-02630_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1 Well Cggtractor Information: g m
St,y�1"Ivv� �°t '�"'t a i,..�� :�
//�• a- FROM TO DESCRIPTION
Well Contractor Name ( y 35 1 ft. ��6 ff
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NC Well Contractor Certification Number 11Z11
* -r ;i t•. SSi UUTER CASING.(for mu7h cased.wialls'OR LINER(if a"Liable
- 1..J 'FROM TO r s'DLAMETER THICKNESS MATERIAL
Morgan Well & Pump, I "�n\NR ,,,.on
�• rL 61/8 '"• Isdr2l PVC
Company Name /� ^ - ^
(sji I 16-JNNER CASING OR?TUBING' i&6thermal dosed lad
2.Well Construction Permit#: FROM TO DIAMETER I 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. tt. in.
Water Supply Well: ,FROMC TO DIAMETER SLOT SIZE THICKNESS MATERL41,.<
❑Agricultural ❑Municipal/Public ft. ft_ in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 r` 20 r` bentonite poured
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEUPACK if a'"livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20i:DRIILINGIOG attac&`addthoaah"sbeets'ifueiess =s
FROM TO DESCRIPTION color,hardness soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft. '40 ft .
4.Date Well(s)Completed: y�`'O�u Well ID# ft. rd ft. So W� �
Sa.Well Location:
O y L� lit tis ++wry ft. ft.
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Facilnity/Owner Name Fac/ility ID#(if applicable) ft. ft.
L� L� �6t a Il,, �\) !n �1 a'CYL ft. ft.
Physical Address,City,and Zip ft. ft.
�(!1606%_ �b 2 Zl"REMARKS -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3'�7 53 421K N ^ 0 I, ZS'?� W
6.Is(are)the well(s):*Permanent or ❑Temporary Sig❑atur ertified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or GNo 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#11 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.s needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: rz 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: OO (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')
Z/b 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"+"
f Borehole diameter: (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
JeL air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: 4^A1114✓' Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources'. Revised 6-6-2018