GW1-2021-02550_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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a ContZactor Information: t,
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14 WATER ZONES'..'S&A 8(��
We Contractor Name - ! ti 2021 F�1{� ft. ��� ft. DROM TO I ESCRIPTION
L ll ft. ft
NC Well Cont a or Certification Number _ �r 0:. t 't`i,)
1' �'F , ,t 1S;OUTER'CASING_for;multi-cased>wells:OR;LINER�i(if-a` heable
sfc
Morgan Well & Pump, y ,, y V ` t!O� FROM TO DL4NIETER THICKNESS MATERIAL
® lfc. ft. 61/8 Isdr2l JPVC
Company Name �^
J( `q (/ :-16:3NNER CASING OR`•TUBING 'eothePmal':clo§ed loo
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2.Well Construction Permit#: ! FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO ~DIAMETER •SLOT SIZE THICKNESS -MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
:183-_GROUT.
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 20 ft. bentonite poured
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19 SAND/GRAVEI;'PACK tf:a"-livable,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test ❑Stormwater Drainage ft. tt
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGI OG-attavti`'additional'sheet3 ff:nvicess '. . ....
FROM TO DES TON(color,h rdness,soil/rack e, rain size,etc.
❑Geothermal(Heating/CoolingQReturn) ❑Other(explain under#21 Remarks) 0 ft. ft. ;�
4.Date Well(s)Completed: O_ LWell ID# 0 ft. ft. (60A �WKJ
5a. ll Location: ft. tt. VL `cAiw
1�dA5 Alk-ks % ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft
'L20 e4"'U A6 ` WI L ft. ft.
Physical Address,City,and Zip � ft ft.
&DOC 21:'REMARKS ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwe0 field,one[at/long is sufficient) 22. tiTicatio
30('11 N 'A 03,4 c6c( W Zsz07,(
6.Is(are)the well(s): Wermanent or ❑Temporary Signature of ell Contractor ate
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 11ENo I SA NCAC 02C.0100 or 15A NCAC 02C.0200 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 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- ' 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@100D
1/0ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) 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: Rotary 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
3 air pressure
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: rtqq
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018