GW1-2021-02085_Well Construction - GW1_20210706

WELL
CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor information:
Jason P Morton 14:,VATERZONES
Well Contractor Name FROM To DESCRIPTION
2953-A D. O rt.
ft, rt.
NC Well Contractor Certification Number
OUTER.CASING-for frtulti=cased=wells OR'LINER iCa`V`hcablc
Morton Drilling FROM I TO DtAMETER T}ttCKVFSC MATERIAL
i R.
Company Name
16.INNER CASING OR TUBING eother at Oosed-loo
2.Well Construction Permit At. ���17. ! FROM I TO I DIAMETER THICKNESS MArERIAt
List all applicable well construction permits(i.e.Ul .,Counraa State.Variance,etc.) ft. ft. in. / . f
V
3.Well Use(check well use): ft. ft,
Water Supply Well: ; 17-SCREEN T
FRO:b1 l'O U1.4METERI $LOT SIZE I THICKNESS M9ATERIAL
OAgricultural IhMunicipaltPubiic ft. ;,,,� Lj OGeothermal(Heating/Cooling Supply) e,sidential Water Supply(single) ft. ft. in.,
❑Indust rial/C0111MUcial ,Residential Water Supply(shared) 18 GROUT
DIrri ation Wells> 100,000GPD FROM TO MATERIAL EMPLACEMENTM4FTIIOD&AMO NT
Non-Water Supply Well: I ft. ft. f- 11
❑Monitoring bRecovery ft. n.
Injection Well:
OAquifer Recharge QGroundwater Reniediation
19'SAND/GRA .EL PALK-(if-applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM I :to MATERIAL t,Mii'LACEMiENT METHOD
CJAquifer Test dStormwater Drainage
OC-xperimental Technology QSubsidence Control tt. ft.
OGeothennal(Closed Loop) OTracer 20:OR]LLINGLOG attach additional sheets'if
OGeothennal(Heating/Cooling Return) Q
{Olher(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
rt. ft. 5 /I_,,,
4.Date Well(s)CompletedlZ Z& `Z'I i Well ID# ft. ft. G
5a.t5'eii Location:
5 ft. ft.
ARC! ' Ic�er< ft. ft
FacilitylOwnej Name Facility tuff(if applicable) ft. ft.
f it, ft.
1>aI 52rs- .one i� 1 �,, ,c r
14
Physical Address,City,and Zip ft. n
arteret
2).REit1ARKS j
County Parcel Identification No.(PIN) I �Org-ssinci Unit
5b.Latitude and longitude in degrees/minuttis/seconds or decimal degrees: rt G i. 'R Section
(if
well field,one latflong its sufficient) 7 J 22.Certification: i
63 J 0/J. J-7 t f N / (✓ j.�v+ �(�f r N+ % /
6.Is(are)the welt{s): ernanent or D:i'ctnporary otCcnilicd Wetl Contractor Date
i
i Ba=signing this Jorna,f lrerebu c,-er•tijv that the aveIto w'r!s ft...)constructer)in accordance with
7.Is this a repair to an existing well: es or CiNo 154 A'CAC 02C.0100 or/SA VCAC 02C.0200 Welt Construction Standards and(bat a copy
ff this is a repair,fill out knotm well consauctio irrforaration and explain the nature of'the of"this record hits been pro4•ided to the welt aavuer.
repair carder#21 remarks section or on die back aJ'dri friar.
23.Site diagram or additional well details:
8.For Geoprobe/UI'P 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 fOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drillcd: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: II V (ft.)
For inutriple welts fist all depths r'Idijjer'ent teraniple-3 u)200'and 2{u 100') Submit this GW-I within 30 days of well completion per the following:
i
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24a. For All Wells: Original form to Division of Water Resources (DWR),
I O.Static water level below top of casing: �% (ft.) Information Processing Unit, 1617 MSC, NC 27699-1 6 1 7
if"ivarer level is above casing.use
24b.For Injection Wells: Copy to DWIt, Underground injection Control(1UC)
Ii.Borehole diameter: 04•) Program, 1636 MSC.Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
r
(i.e,auger,rotary,cable,direct push,etc.) county environmental health departmentlof the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 1100.000 GPD: Copy to DWR.CCPCUA
[�c� Peril m,Progrd 1611 MSC.Raleigh,NC 27699-1611
13a.Yield(gpm) "zo Method of test: AIR �
13b.Disinfection type: oRtm a_ Amount:77=
Form GW-1 North Carolina nr narnm-m of V 4............