GW1-2021-07898_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well n actor Informati
34 WATER+ZONES
FROM TO DESCRIPTION
Well Contractor N e
(� — A ft. ft.
ft.
ft.
NC Well Contractor Certification Number 15 OUTERCASING for:multi-cased:well3`_ORTiINER ifia
Morgan Well & Pumps I N C FROM TO DIAMETER' THICKNESS MATERIAL
ft. fL 61/8 i" sdr21 PVC
Company Name ? (� .,16 JNNER CASING ORITUBING ""eothermal closed3oo -
2.Well Construction Permit#: � 1 FROM TO DIAMETER THICKNESS T MATERIAL
List all applicable well construction permits(z.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: tt L7-SC REE N r_ :IT- >. Y . :-_ .;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) jRResidential Water Supply(single) ft. ft. in.
❑Industrial/Commerciai ❑Residential Water Supply(shared) ;18 GROUT
❑h-i ation ❑Wells>100,000 GPD FROM TOj` MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rc• 20 rt• bentonite poured
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
.19�SAND/GRAVEL=P.ACK ita'livable
❑Aquifer Storage and Recovery Cl Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geotherrnal(Closed Loop) ❑Tracer 20DRTrT7NGiOGattack=additioualhee`ts;ifnecess �. _'_
FROM TO DESCRIPTION color hardness,soil/rock type,gain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q ft. 1 ft.
4.Date Well(s)Completed: 0 (�z� I2_( Well ID# t S ft. 3 ft dlyA
5a.Well Location: 3 SStt.
.�ntt. /
Facility/Owner Name Facili ID#(if applicable) ft. ft.
11 S� Y1 A W�bIr� ��,'G\\\�� ft. ft. _ il
Physical Address,City,and Zip
ft. fL
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlong is sufficient) 22. tcafion t " s ':•'1
3S.Sako N W
6.Is(are)the well(s): Permanent or ❑Temporary Vae Certified Well Contractor Date
ng ibis farm,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.0100 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 we.11 owner.
repair under#21 remarks section or on the back of this fonn.
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 I 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 i(different(example-3@200'and 1@100�
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"+"
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
o + Program, 1636 MSC,Raleigh,NC 21
7699-1636
12.Well construction method: Ro`a'1••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 departulent of the county where installed
f
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 27699-1 6 1 1
13a.Yield(gpm) Method of test:
air
Disinfection type:3\\TJrwvU Amount: UrL�
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018