GW1-2021-06671_Well Construction - GW1_20211007

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Wkl�ontracto . � aft n{ � i
� `..14.iWA1'ER-'ZONES .4„
�- FROM TO •DESCRIPTION
Well Contiatr Name fL
(�� ft.
NC Well Contractor Certification Number \/' �r�`n�
INC
� r� r`G�" 15z;OUTER CA$ING(fo'r:mulh,casedswells),ORZINER:;f�ii hcsble): ,
Morgan Well & Pumps I I V C e��Q���C,Qir'`O� FROM TO DIAMETER' I IDCKNESS MATERIAL
ft. Q ft- 61/8 ; to sdr21 PVC
Company Name V'S
Q a+
'� / 16 INNER CASING:OR-TUBING eo'thei•mal`dosed loo x.a._,.
2.Well Construction Permit#:��. )V FROM TO DIAMETER THICKNESS . MATERIAL
List all applicable well construction permits#.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. tt ]n•
Water Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Pubhc ft fL in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.j
❑Industrial/Commercial ❑Residential Water Supply(shared) 18i_GROUT, .z-',` __
❑h-ri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rc• 20 rt bentonite poured
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation _
19:SAND/GRAVEL PACK tf a lieable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD£t
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20i DRILlING`LOG atfa`eh=addtttoual sLee,ts if'uecess =
FROM TO DESC TIO color,hardness,soil/rock e,•rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) [t. ft \Y
4.Date Well(s)Completed: Well ID# O ft.
5a.Well Location:
� .�n ft. ?,mot• � t,
Facility/Owner Name Facility ID#(if applicable) ft. ft
e ?A ``S /t Z,� H ft. ft
ical Address,City,and Zip \ v ft, tt
"211,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,oJneeolat/lonnfg is sufficient) . �( Q �J 22.Certification:
<�a r/
6.Is(are)the well(s): InPermanent or []Temporary Sign e f Jrtified.Well Contractor Date tng thorm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [nNo 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:' �1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L�.JV (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 00'and 2@100�
]� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: v (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)
o t�� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rota'1
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departmentI of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
air pressure Pemrit Program,1611 MSC,Raleigh,NC 27699-1611
't
13b.Disinfection type Amount: Z
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources G Revised 6-6-2018