GW1-2021-06666_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W 11 Contractor Informati JOA TOn
14.:R'A'•TER`ZONES k�r,.;:.:� "..'sr.:,•� 1 .r.,�t =� � . .�' .:_::
Well Contract am 0 DI FROM. TO DESCRIPTION
r ft. ft.
QC 'm13 V ft. ft
rep _
NC Well Contactor Certification Number (C� -
i1�3�0 Jv110(� FROMUTER':CTOSING foramDL�edR, OR RSS a MATERIAL
Morgan Well & Pump, INC�r&3 o�NR
I ft ft 61/8 ji" Sdr21 PVC
Company Name
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2.Well Construction Permit#:
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constriction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM
FRO TO DIAMETERS SLOT SIZE THICKNESS MATERIAL J`
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) (PResidential Water Supply(single) ft- ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: 0 fl' 20 ft- bentonite poured
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation r
:193ANWGRAVEUPACK tf livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer '202;DRII LING LOG attach`additidual"sheets if riecess _.,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Ff
TO DESCRIP N(color,hardness soil/rock a In size,eta
fL
3
4.Date Well(s)Completed: Well ID# ft.
5a.Well Lo`ca'on: fc w
ft. p
C,
Facility/Owner Name Facility ID#(if applicable) ft. ft.
jtcal Address,City,and Zip G .��/� ft ft
t`����IV VI { !✓O s21'.';REMARKS_
County Parcel ldentification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,,one latt///llong is sufficient) �g G� C]7� qB '
flcationA_
0 N ~ (:),q 1 1 v W
6.Is(are)the well(s)• *Permanent or ❑Temporary o ertified Well Contactor D e
form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well• ❑Yes or 4*No 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 So provide additional well construction info
construction,only I GW-1 is 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:11 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100')
)y+I 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
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: Rotary 24c.For Water Supply and Open-]i Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: _
13b.Disinfection tyNc Amount:
Fort GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018