GW1-2021-02605_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Aell Contractor Informali©:
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-_ia;,wnTER:zoNEs.�. ....
Name u I70M TO DESCRIPTION
Well Contractor
1 2021 Q ft. ft.
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ei.1131� f[. ft.
NC Well Contractor Certification Number r�Cr � .�to _
IN
{^11'�s1 t Cc LiOD ,LFRO UTER.0 SING-,(f6r,`mDLAMETERe�-OTHLNERSS a hMATERIAL
Morgan Well & Pump, IBC c`�`�� ;� ' 2 ft. fL 6 vs Sdr2l Pvc
Company Name `' O^
[/-'I P G 16iIlV- NER`CASING;OR:TUBING.`eotliermal'closed loo
2.Well Construction Permit#: FROM I TO DL4METER THICKNESS M.4TERLIL
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.
l �17.79CREEN +
Water Su d`
PP Y Well: FROM TO DL4METER SLOT SIZE THICKNESS MATERL4L
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) AResidential Water Supply(single) ft. ft. in•
❑industrial/Commercial ❑Residential Water Supply(shared) fig:GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL" EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• bentonite poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
SAND/GRAVEL kCK ifib licatile
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD{'
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer -20:DRIILINGLOG[ifficEadditiouilsheetsifuecess -_
FROM To DESCRIPTION
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) color,hardness soiuroektype, ram Sae etc.)
Q q Y 6 ft. C O ft. e'
4.Date Well(s)Completed: `" Well ID# 0 ft' 3�ft- �--
5a.Well Location:
Vqu( / ft. f
I Facility/Owner Name Facility ID#(if applicable)
ft. ftL
(y� ��� 1" �r� •v� [/' �liV/!'t t'D�) ft. ft
Physical Address,City,and Zip ft ft
cl 3 �1I6 ,21:ItFMARKC =",` - _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one la ng is sufficient) 22.Cep1 on:
3Y� 8� N � � � W �
6.Is(are)the weli(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *No 15A NCAC 02C.0100 or I SA 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 1 GW-1 isvded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:I � �+ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / 9 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@100D
4/0 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"+•'
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 (in.) 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
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13a.Yield(gpm) Method of test: air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611 13b.Disinfection type:. r�►/Iy��✓ Amount: v Q
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018