GW1-2021-06672_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD(GW-1.) For Internal Use Only: .
1.Well Contractor Information:
,14:rR?ATERZONES
Well Contractor Name b FROM TO04 DESCRIPTION
ft
NC Well Contractor Certification Number
�,tRtJ 15:UU.TER CASING for mib ae , INable)
Morgan Well & Pump INC •.�'���CCf ,O� TO DL4METER TffiCHIVESS MATERIAL
' �, n� ft• ft• 61/8 t" sdr21 PVC
Company Name '/D,y�" ,46:INNER:CASING.OR-TITBING,'eother`tnal`closed.loo"
2.Well Construction Permit#: (/� //U FROM To DIAMETER TaICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROMC ELTO znx DIAMETER i SLOT SIZE THICKNESS •' MATERIAL.
❑Agricultural ❑Municipal/Public ft. ft. in.:!
❑Geothermal(Heating/Cooling Supply) PResidential Water Supply(single) ft. ft. in..
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROTJT
❑Iri ation ❑Wells>100,000GPD FROM TO MATERIAL +EMPLACEMENT METHOD&AMOUNT
F
Non-Water Supply Well: 0 tt 20 tt bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19%SAND7GRA�I;-PACK'if.a `livable - _ .'.;:, ,
❑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 ;20 DRILLING==L'OG attacli`addrtioual;3heetsif recess %`
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION ION(color,hardness soil/rocka pram size eta)
ft. ft. V.
Ited c
4.Date Well(s)Completed: '� Well ID# 30 ft. ft. D
Sa.Well Location: ;�:/ a ft. ft. b'
e.14W ft.
LFacility/Owner Name / (�// �Fa/ciillity ID#(if applicable) ft. ft.
6�� �L L�LI l liV 146be vit ft. ft
Physi Address,City,and Zip ft fL
Y' vY/ A6 � 21.REMARKC.M,e": e.,,,- f_- _ nr:3� _ 3O -
rT
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well ;Id�n�jaUl"ng is fficient) � �� 22. 'lcation:
6.Is(are)the well(s): IlPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,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
constriction,only 1 GJ 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: v (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierew(example-3Q200'and Q10q
b 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"+" -
24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 (in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rita'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 department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,600 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) A Method of test:
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
/ l E
13b.Disinfection type:v^G4VU. el Amount: II
I
Form GW-I North Carolina Department of Environmental Quality-Division of water Resources: Revised 6-6-2018