GW1-2021-06668_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
M� ` -A4,"':WATERVZONES
M TO "DESCRIPTION '
Well lCContractor Name' ��( 0 �r,\�� ft. ft. r
o/ `�`C��g ft. ft.
J•,or _
NC ell ontractor Certification Number �r0� sq,"N'
\`,a '•tjO�Nt FROM
TO DIAMETER en OTHICKNESS a hMATERIAL - -
Morgan Well & Pump, INC 1 ft. fL 6 1/8 ' '" Sdr21 JPVC
Company Name
�16;'INNER�C' ING:OR TUBING "etithermshdo§ed loo )
2.Well Construction Permit#: 11��V 1 /F'1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perntlts(� i.e.UIC,County,State, Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft. ft. in.
CREE
Water Supply Well: .FROM TO _� DIAMETER SLOT SIZE THICKNESS MATFRI
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothennal(Heating/Cooling Supply) *,Residential Water Supply(single) ft. tt in. j
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MMATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
:d9SAND/GRAVEL-P.AG1C da �licatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer -,.20;DRIT.LINGLOG'ittach'ad'ditidnil sheets if necess
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION icolor,hardness soil/rock 67pe,grain sae,etc.
f ft. P.- ft.
4.Date Well(s)Completed-9—1J Well ID# ft. �• ft. 1
Sa. ell Location: TT" ft. I D1 ft.
ft. ft.
F cility w r_ ame Facility ID#(if applicable)
obl6a , C ft. ft is:
ical Address,City,and Zip i �o J� / ft ft
b .21 ft
--
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one
tat
/long is sufficient) 22*
cation:
c 11.�1 N — , W g1
6.Is(are)the well(s): permanent or ❑Temporary Si a Certified Well Contractor Da
B)signi this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No 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#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: _ (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(exampTTTe-3 00'and 2Q100D
4,� 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: Rotary
I
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
��' _ air press u re Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
E
13b.Disinfection typ : Amount: 4 012
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018