GW1-2021-06674_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD (GW-1)e� 9 For Internal Use Only:
1.Well Contractor Informa' n:
1 14:;WATER'ZONES
OM I TO DESCRIPTION
Well Contr cto Name �\�` `�� ft. ft.
�qZZ_ 1 r
rP
QC�'' n ft. ft
NC Well Contractor Certification Number
\`I�Jt\,• Q oUTER:CTOSING,`for.mDLSMETERells ORffi �IJESSa`LMATERIAL ..
Morgan Well & Pump, INC ft. I ft 61/8 JSdr21 JPVC
Company Name 16 DWER CASING OR_TUBING:(peoW6 inaLcaosed400
2.Well Construction Permit#: L� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.U1C,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft in.
17.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS _x MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) tBResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -C GROUT _ `
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL
MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- benton'te poured
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
.19 SAND/GRAVEI PACK if a' licatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD$
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer >e20 DRIILINGILOG,Otticfiaddthoiiah'sheets'ifriecessa s_
FROM TO DESC TIO color,hardness,soil/rock e,g rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Y� ft. ft
Ts
4.Date Well(s)Completed: Well ID# Z J ft. ftVDA
5a.Well Locatio ft. ft.
es
�y�ft. i 1 .ZL 7�i
Facility/Owner Name Facility ID#(if applicable) ft. ft
I01 ft. ft.
sicaI Address,City,and Z' ft. ft A UZ .21r<REMARKS„ -
County Y " Parcel Identification No.(PIN)
51b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22. a cation:
N W Z--J ..
6.Is(are)the well(s): QdPermanent or ❑Temporary Si a Certified Well Contractor Dat
B}signi is form,l hereby cert�&that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or SNo 13A NCAC 01C.0100 or 15.4 NCAC 02C.0100 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 1 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: 200 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3 a@200'and 2Q100')
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"+"
6 24b.For Injection Wells: Copy to,DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotar Y 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
C
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:
131b.Disinfection ty4bloy K Amount: 117,
Form GW-1 North Carolina Department of Environmental Quality-Division of water Resources Revised 6-6-2018