GW1-2021-07860_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
ell Contract ormation:
14.WATERZONES r:
FROM TO DESCRIPTION
Well Con for Name
ft. ft
ft. ft
C Well Contractor Certification Number INC
n ,.15 OUTER CASING'foi.'"mdlti:&i "" elli OR`ZINER ifa' hcable ,.
Morgan Well & Pump, I N C FROM TO DIAMETER THICKNESS MATERIAL
ft. rt. 61/8 i" sdr21 PVC
Company Name
' ����� �i6.3NNER;GASINGOR TUBING eothermahcldsed7oo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft tn.
Water Supply Well: 17.'SGREEN
FROM TO DIAMETER :(hSLOT SIZE THICKNESS v MATERIAI. -
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:_GROiTf. ti,, F: f'
StIrrigation ❑Wells>100,000 GPD FROM TO i- MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
❑Monitoring ❑Recovery ft. fL
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19'SAND/GRAVEL`PACK if a"licalile Nr'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer [20 DRUMNGLOG'itticl addittoual'sheets'ifnecessar
LL
❑Geothermal(Heating/Cooling Return) ❑ FROM TO DESCRIPNcolor,hardness,soillrock in size,etc.)
Other(explain under#21 Remarks) C�- ft. ft
4.Date Well(s)Completed:� •'�' V Well ID# ' ft. ft. r+_
Sa Well Loc 'on: kn ft. ft
ft. ft irw
Facility/Owner Name Facility ID#(ifa�pplicable) ft. �} fL
�� ` ft ? pj
Physic ft
Physical Address,City,and Zip
t . ft
CL2,7,5 a.a1 i
J
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
tf well field one IaVlon is sufficient t
C d, 9 g ) 22.Cer' tion: fit''t•_'`'
N <-VS Z > �6 �
6.Is(are)the well(s): Permanent or ❑Temporary Si f ertified Well Contractor Dat
in th'form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *No 15A NCA 21C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out,brown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 421 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: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �O (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)
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 dep"ent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
� air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection ty Amount-
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018