GW1-2021-00462_Well Construction - GW1_20210210

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jason P Morton 14.,WAT.ER;ZONE$ ,.
FROM TO DESCRIPTION
Wei Contractor Name /
2953-A ft. ft.
NC Well
Contractor Certification Number I5:?OUTER CASING foianulti-cased'wells OR LINER.(65" livable
Morton Drilling FROM TO D1A:�IETER THICKNESS MATERIAL
in.
Company Name 16.INNER CASING OR TUBING eottiermalclosed loo
2.Well Construction Permit#: re%.3 FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Counh,State, Variance,etc.) �. ft. �t. in. D 1
G
3.Well Use(check well use): ft. ft. in.
1 ;777:SCREEN
Water Su
PP Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑%/Municipal/Public �ft. Z t. in, �e,4
❑Geothermal(Heating/Cooling Supply) IzKesidential Water Supply(single) R. ft to
❑Industrial/Commercial Residential Water Supply(shared) 3$.GROUT
❑Irri anon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT ME OD&AMOUNT
Non-Water Supply Well: R. ft. 00
❑Monitoring ❑Recovery
Injection Well:
fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
09.SAND/GRAVEL'PACK'if a titiciihte
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. Tj 0 re-
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING>LOG.:attoch'hdditioriahshcets�if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM rt. TO ft. DESCRIPTION color,hardness,solUrock a rain size etc.
4.Date Well(s)Completed: WellID# ft. G
Sa.Well Location:
Facility/Owner Name Facility ID#(ifapplicable) rt. ft.
Physical Address,City,and Zip •LS !�u •t' ft. ft.
Carteret "21.RENTARKs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iaillong is sufficient) 1 / 22.Certification:
3y `50'0Y, C?-7 j/ N76°�� lytd g W Z
6.Is(are)the well(s): ermanent or ❑Temporary Lure of Certified Well Contra or Da
By signing this form,I hereby certij.i,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes IJNo 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 inform i n 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. .23TSite diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells h u s�'i f't;�a o�ilinay use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMI3t"ET�bfW y (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: ©&L
r 1) 2024 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list a!!depths i di Brent(example-3 cb20 'and 2 00 ^` n Cr�SubrtiitSllis GW-1 within 30 days of well completion per the following:
P P f Jf ( P C ®1 �.^IgC`71
nrt:f0h
of casing: ),jL a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top g: (O (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use'•+••
11.Borehole diameter: in (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
,�� ]�� / Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: /TU'ltlarl�Y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 01 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
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Y 6 Method of test: f�
� Oy
13b.Disinfection type— di Amount: (—
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018