GW1-2021-02657_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i
I.WellVctrfor Information:
-•'� cam'%"��r 14.WATERZONES'::,'.' :`". .,. ;' :_i:�.:
„�.. FROM ITO DESCRIPTION
Well Contractor Name ft. I ft.
ft ft , .. ..
NC Well Contractor Certification Number
(�t-�1ZIt 15:OUTER (for multi=cased'well`s)Q12 L•TI�F.R if a-
r"rore"'sil3 .60 DIAMETER THICKNESS MATERIAL
r• ',f,,..:.. FROM
Morgan Well & Pump, Inc. I�e�OCI;"�i`^'�t-� r, ; 1�
,r3 :^, ..1.0 — +1 ft. X ft 61/8/ in. sdr21 pvc
v�
Company Name p
p u' 16:'INNER G G ORTIIBING' eotherma`I'clos'ed=lot ' ,
2.Well Construction Permit#: FROM I To DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits e.UIC,County,State,Variance,etc.) ft ft. in.
ft ft in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT STZE THICKNESS MATERIAL
:]Agricultural OMunicipal/Public ft ft
J Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft
Industrial/Commercial DResidential Water Supply(shared) -18:GROUT.:
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring Recovery ft. ft
Injection Well: ft. ft.
Aquifer Recharge r Cn-oundwater Remediation
�, 79.SAND/GRAVEL'PACK Cif a licable
Aquifer Storage and Recovery [p�3}Salinity Barrier FROM To MATERLAL EMPLACEMENT METHOD
_ Aquifer Test !3 Stormwater Drainage
Experimental Technology Subsidence Control ft. ft
'Geothermal(Closed Loop) Tracer 2b.DRE LINO.LOG'(ittacli'additfonsl sheets:if necei `' '_;::: - ==
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
i'l Geothermal(Heating/Coohng Return)�+� i Other(explain under#21 Remarks) ft. ft. `I'
4.Date Well(s)Completed? 1 l We11ID# 17 ft i 15ft.
5a.We Locatjqn: _ J
y ft ft b ku e [a 0-41 kNg n
Facility/Owner Name J Facility ID#(if applicable) ft
1-7
ft ft
ft
P( al Address,City,and Zip ft
-21'RRMARKC �, ..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
tf well field,one lat/long is sufficient) 22. r cal f
Is D
6.Is(are)the well(s) Permanent or Temporary
rahigl5A
o Certified Well Contractor Date
nin is form,1 her•ebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or VNo NCAC 02C.0100 or,15A NCAC 02C.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 owner.
repair under 421 remarks section or on the back of thisfor-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 to,provide additional well site details or well
construct' 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well tpth below land surface: 1 X (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffen ent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: (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 Injection 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: construction to the following:
(i.e.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
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection typ • Amount: completion of well construction to'the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016