GW1-2021-07795_Well Construction - GW1_20211102

f
f
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
I
1.W c r Informption:
I
s14:WATER:ZONES a x,:.,t FROM TO DESCRIPTION
Well Contractor
ft. ft.
NC Well Contractor Certification Number OUTER'CASING fdr_:multt ca_ sed,_wells OR LATER;tf'a hcable
Morgan Well & Pump I N C FROM TO DL4METER THICKNESS MATERIAL
' ft. ft 61/8 Sdr21 PVC
Company Name 16;INNII2;CA51NGsOR;T[IBING'"e`rthermaLclosed�oo
2.Well Construction Permit#: A FROM TO DUMETER THICKNESS 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.
C PWater Supply Well: FROM TO I DL4METER J SLOTSIZE I THICKNESSMATERIAL
❑Agricultural ❑Municipal/Pubhc +11
ft. in.
❑Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft
❑Industrial/Commercial ❑Residential Water Supply(sbared) 18.GROUT „r k
01rri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
!
Non-Water Supply Well: 0 ft. 20 rt. bentonite poured
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19`SAND/GRAVEL',PACK tf a""livable w= 5
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer i�-20:DRIL7 VGLOG a`ttich*iddittoiiil'3heeti-if decess '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock e,•rain size,etc. ~
/) ft. M ft i r
4.Date Well(s)Completed: Well ID# to ft. 315 fL
5 Well Location: 50 ft. O o fl- F✓C-1 r
ft J
Facility/Owner Name pFacility ID#(if applicable)
4q0 r r V 1, 6 ��t Ltd -'WJ%L CSC A01I
P sical Address,City,and Zip ft. ft. V611
( ryVs 21'32E191ARKS .a=
County Parcel Identification No.(PIN) 3rtq ' you
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.
S© Ication:
N : C.I L W J(bVIA
6.Is(are)the well(s): Permanent or ❑Temporary Si e o e ified Well Contractor Date
By signing t ns form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or I[IiNo 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 Ito provide additional well construction info
construction,only 1 GW-I 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 dierent(cramp e-3@200'and 2@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: cl,,11..0 A) 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: o (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rota'f-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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
zo a i r pressure Permit Program, 1611 MSC,Raleigh,NC 27699-1611
j
13b.Disinfection type. Z Amount: "'
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018