GW1-2021-02084_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD(GW-1) —For Internal Use Only'
1.Well Contractor information:
Jason P Morton :�MWATER ZONES:.:
FROM TO DESCRIPTION
Well Contractor Name ft.ft. A2
0
2953-A
NC Well Contractor Certification Number 115.'OUTER CASING.-(for,iiiulti-6sed.'wells) LINER(if
0
Morton Drilling FROM DIAMETER in. RTHICKNESS AL
ft. ft.
Company Name
Ik.-INNFR CASING OR,T BING(geotheirnal closid4diiii)
2.Well Construction Permit#: 9S6_-L Z_-7 FROM TO- i I DIAMETER THICKNESS I MATERIALc List all applicable.well construction permits(i.e.UIC,County.State. Variance,etc.) ao ft.:1 4 : in.
�Ov _
3.Well Use(check well use): ft.
1,7.SCREEN,
Water Supply Well: FROM TO .'DIAMETER, SLOT SIZE, il THICKNESS I . MATERIAL
OAgricultural OMunicipaUPublic ft.
in.,
oGeothennal(Heating/Cooling Supply) esidential Water Supply(single) in.
01ndustrial/Commercial ftOResidential Water Supply(shared)
:GROUT tcz�
OIrrigation 0Wei Is>100,000 GPD FROM TO MATERIAL 'EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - 0 ft. v rt�
OMonitoring ORecovery ft. ft.
Injection Well; ft. ft.,
OAquifer Recharge OGroundwater Remediation
PAck Cif applicable).19.SAND/GRAV9L
OAquifer Storage and Recovery OSalinity Barrier FROM I TO/ MATERIAL EMPLACEMENT METHOD
OAquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control R. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLIN,G LOG attachadditional 9heels'ifnecessary)
C10
J , , typ,g ,
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM To DESCRIPTION color hardness soilfrock e rain size
ft. ft.
4.Date Well(s)Completed: WeIIID# ft. ft r dv
5a.Well Location:
ft.
jb4VIb
Facility/Owner Name Facility ID#(if applicable)
gJ JA P,le v LW AZWaA t' , ly'�2 ft. ft. D
Physical Address,City,and Zip
Carteret ,"21.REMARKS ,'
County Parcel Identification No.(PIN)
processing Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Inform3tion
LJV V I-%Stsc';Ofl
(if well field,one[at/long is sufficient) 22.Certification:
N —W
7-
6.Is(are)the well(s)* Permanent or OTemporary � azure ofCcrtifi4d Well Contractor Date
4v signing this form,I herebv certify that the wells)was(were)constructed in accordance ivith
7.Is this a repair to an existing well: E es or MNo 15A NCAC 02C.0100 a)-]5A AICAC 02C.0200 Well Construction Standards and that a cqpv
if this is a repair,fill out known well construction it formation and explain the nature of the oj'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 I GW-I is negded. Indicate TOTAL NUMBER ofwells (add'See Over'in RemarksI 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 I 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- .15 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
trivater level is above casing.use
11.Borehole diameter: (in.) 24b. For Injection Wells: Copy to,DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 217699-1636
12.Well construction method: 460-11� 1z 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
I -
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ver 100.000 GPD:Copy to DWR,CCPCUA
1,4) Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gp-) 25 Method of test: AIR
13b.Disinfection type:ch to A14-7-0— Amount:
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018