GW1-2021-07819_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1_3 �u tractor Information:
Well Con cto Name FROM TO DESCRIPTION
ft. fL
A ft. ft.
NC Well Contractor Certification Number /� 15'OUTER;CASING fo`r,.iiWti„case$'svells;OR- Cif a` Ircable',
Morgan Well & Pump, IN C FROM TO DIAMETER MATERIAL
ft. fL 6 1/8 i in 1s`dr2'S,
1 1pvc
Company Name
16 INPIERi'C ING OR TUBING' eotherm�dosed loo
2.Well Construction Permit FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. IL in.
3.Well Use(check well use): ft. fL in,
I,7
Water Supply Well: SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS) MATERIAL '
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) t 18s'GR6U1 ' y
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
,-�19!SAND/GRAVELPACr(if,'Wpliable
❑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) ❑Tracertyp:20 DRILLaTGIsOG`atta�haddraonalsheets dnecess „- ?. ,,f.-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rocka rain s' etc.)
b ft. p ft. �\Y=L-
4.Date Well(s)Completed: IV 1 Well ID# 1 U ft- fL
5 Well Location aS ft- �A 'L d Y rQl'1r�
CrGr� Qrn rir� ft. ft.
Fa
cil
i
ty/
/OOwne
r- m
mee Q���/� Facility ID#(if applicable)) q
4J s s `r`^ �"' �, )_e i`y�N �l�3 / ft. ft.
ON
Ph sical"Address,City,and Zip ft ft r n` 1s
ytt U \i. ,;21--REMARKS,-sr
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Cer' ation:
35.(Q2349 N � 0 o(Z). 165 W U S
6.Is(are)the well(s): lbPermanent or ❑Temporary Signature Ce ied Well Contractor Date
By si to th'f m,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IiNo !SA C 0 .0100 or 15A NCAC 02C.0200 Well Consauction 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: 0= (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdlferent(example-3Q200'and 2©100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: SC) (fL) 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)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Iota rY 24c.For Water Sly and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmentalupp 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
2 air pressure Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
i
13b.Disinfection type: Vve/ Amount: aZ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018