GW1-2021-06669_Well Construction - GW1_20211007

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor nformation:
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Well CO tractor Nam e FROM ft TO ft DESCRIPTION
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NC Well Contractor Certification Number
�S(O� � 15OUTER:C-ASING for`mulh casedivellsf:ORLIl�TER`ifa" hcable c_ _
Morgan Well & Pump, INC ,^«y � �E�1:o FROM ft. ft 6 1 8 TER : T M2�SS NUTE
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Company Name
:16:INNER•C 'OR;TUBING 'edtbermal'ddsed.loo `,
2.Well Construction Permit#: � FROM TO DLaMETER' 2HIcxNFss _ 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�ErTO M DLAMETER` SLOT SIZE THICKNESS �MATERLIL
❑Agricultural ❑Municipal/Public tt ft in.1
❑Geothermal(Heating/Cooling Supply) VResidential Water Supply(single) tt
❑Industrial/Commercial ❑Residential Water Supply(shared) 18r.GROUT r _r
❑Im ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f` 20 ft bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:==SAND/GRAVEL PACK rf a 'licab`7e -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. tt.
❑Experimental Technology ❑Subsidence Control ft. tt.
❑Geothermal(Closed Loop) ❑Tracer 20sD}Ln•rGZOG(attach"addrtitiiial`sheefs if recess '-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESC TION itolor,h rdness soil/rock type,grain sae,eta)
tt. ft
4.Date Well(s)Completed: Well ID# 5 ft. 6 tt r
5a.Well Loca' Tft. ft. r G
V tt. t _ L
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Facility/Owner Name Facility ID#(if a licable) v ft. ft
�,r►r,arc, ft. it
./awl Ad�drre/s�s,\Cit�y,and Zip /off G ft ft
;REIVARKC
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/loonng is sufficient) ?0 222.Certification:
� J< O1�U N — C1V W ? �!
6.Is(are)the well(s): nPermanent or ❑Temporary Siggiga
C
ced Well Contractor Da
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By ,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo IS or 15.4 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 tinder#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: ZOV (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 1@I00')
Q 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 24b.For Injection Wells:Copy to,DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary24c.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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,600 GPD: Copy to DWR,CCPCUA
2V air r1 res s u re Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: air
13b.Disinfection type:rv\ �L/Amount: 7/
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018