GW1-2021-02103_Well Construction - GW1_20210706

vvr,l.,ju it-yiNbIRUC TION RECORD (G,W-1) For Internal Use Only:
1.Well Contractor information:
Jason h Morton 14.)PATER ZONES -
Well Contractor Natne FRO:Nt TO DESCRIPTION
2 t jti.
2953-A
rt. ft.
NC Well Contractor Certification Number 15.OUTFR CASINO"7orrtuih'¢ised welis OR LINER if i"`licable ,
Morton Drilling FROM To DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
j 16:-INNER'CASING OR TUBING."eathcrniiit elose&lob =:
2.Well Construction Permit#: FROM To I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County.State. Variance.etc.) ft. 5 rt. in. G-
3.Well Use(check well use): it. ft. in.
Water Supply Well: 17 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS ;MATERIAL
OAgricultural OMunicipal/Public ft. in
DGcotherna!(Heating/Cooling Supply) ' iesidentiai Water Supply(single} ft. rt. in:
0 Ind LlStrial/Commercial OResidential Water Supply(shared) T&CROUT
01fri ation ❑Wells> I00,000 GPD FROM TO NATERIAL, EMPLACEMENT METHOD&AMOUNT P
Non-Water Supply Well: ft. 2-O ir. � dre D;,i S
OMonitoring ORecovery ft. ft.
injection Well: f,. ft.
DAquifer Recharge OGroundwater Rcmediation
19rSANBIGRAYEL�'PAC'K if a a"Iicable
OAquifer Storage and Recovery OSaiinity Barrier FROM 1-0 MATERIAL EMPLACEMENT METHOD
0Aquifer Test OStornwater Drainage H.
OExperimental Technology OSubsidence Control ft. ft.
OGeothennal(Closed Loop) 0!facer `10t ,DRILLING"LC!G'atcacii additional sheets d necessai
FROM TO DESCRIPTION(color,hardness soil/rock type. rain size etc
OGeothermai(Heating/Cooling Return) pother(explain under#21 Remarks) Q ft. L ft.
4.Date Well(s)Completed: ✓ '2 Well ID# It.
5a.Well Location: + azc ft 2— '0
It
Facility/Owners Name t Facility lD#(if applicable) ft, ft. „
I Y 4 4 d fl 1 w7 `. � y ' E.'
Physical Address,City,and Zip it. !t
Carteret 21:RERiAR1iS
jfb C3fi�3isit!I F
T;'11t}fI
County Parcel identification No.(PIN)
5b.Latitude and longitude in degree0minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certification:
; 51 y2 ,8 `' N'71r1�39 ` 5t'ar5 W pp
na re of Certified Well Contractor Date
6.is(are)the well(s): ermanent or O'rentporary
y situing this/ornt.l herebv cerliJb thal the wells)tutu(were)cartstrltcied in accordance ndth
7.Is this a repair to an existing well: OYes or�10 15A NCAC 02C-0100 or 15A NCAC 02C.0200 Welt Construction Standards and that a copy
/f7his is a repair,Jitl out knowtl well cwun•uction information n tylain the nature of die of This record has been provided to the well owner.
repair raider#21 remarks section or on the back oflhis form. 23,Site diagram or additional well details:
S.For Geoprobe/DYT or Closed-Loop Geothermal Wells having the same YOU may use the back of this page to provide additional well construction info
construction,vniy 1 GW-i i needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drifted: az 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-I within 30 days of well completion per the following:
For multiple welts list all depths ffclifferent(example- 1@200'and Z u 100')
f 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: f -(ft) information Processing Unit, 1617 MSC,�Raleigh,NC 27699-1617
tf water level is above casing,use "
24b. For injection Wells: Copy to DWR, Underground injection Control(IUC)
11.Borehole diameter: (in.) / Program, 1636 MSC.Raleigh,NC 27699=1636
12.Well construction method: ` �`l 24c.For Water Su Iy and Open-LoopLothermai Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) Coll ni7 environmental health department tiff the county where installed
1 ,
FOR WATER SUPPLY WEI,LS ONLY: 24d.For Water Weil-.;producint over Ibo,000 Grp: Copy to DWR.CCPCUA
13a.Yield(gpm) /�f Method of test: AI R
Permit Program, 1611 MSC,Raleigh,NC 27699-16I t
13b.Disinfection typeaY/'t 091 AC-1 Amount:
Form Gw-1 North Carolina Department of Environmental Quality-Division of Water Resources -