GW1-2021-02645_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. It Contractor Information:
�Sla �xzolvEs .t
FROM TO A DESCRIPTION
J
Well Contractor Name ?G/S ft. 136 ft.
3 S^I 'Jr'�J• � � '
`, ft. ft
l�,>t
NC Well Contractor Certification Number r p `
,IS OUTE&.EASING.(ftir iiiulh casedwells'OR'LINER`if�a'
Morgan Well & Pump I N C t , r r i� FROM TO DUMETER THICKNESS MATERLAL
3 a ` c.�.- ft. ft. 6 1/8 in. Isdr2l JPVC
Company Name t`t V v`'° - _
I (� �1 t G 16:IlVNER CASING OR TOBIIVG e'd'fhecmit'cl6sed Ioo
2.Well Construction Permit#:Wd 'BOO-7 6--I J6638 FROM TO DUTAETER TCKNESS MATERIAL
List all applicable well constriction permits rz.e.UIC,County,State, Variance,etc.) ft. ft HI m.
3.Well Use(check well use): ft. ft in.
Water Supply Well:
PP Y FROM TO DL4,METER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft• ft in.
❑Industrial/Commercial bResidential Water Supply(shared) fg;_GRODT `
❑Irrigation ❑Wells>100,000 GPD FROM TO i 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
;19:=SAND/GRAVEL PAtZR:rf a'-liiable . -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERUL PLACEMENT METHOD
El Aquifer Test ❑Stormwater Drainage f[. ft
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer ,20 DR]LLING]LCrG i ti6"a-ddrtidnil iheets ifiiecess
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soillrock ram a size,ete)
40 ft. S ft rieJ b.
4.Date Well(s)Completed: Well ID# / S f[. [ C ft. p/ 4-
5a. ell Location: to f[. e"ft. �7 J
G`� tu�G (�f 1 5-s ft. �t�j ft
Facility/Owner Nit a Facility ID#(if applicable) ft. ft
-71 r0 1-1 �kllp�;C,a is rod11 ft. ft
Physical
fAddress,City,and Zip pj� /���yj,�(��/� {/ ft. ft.
kG L°V l�W✓�f6yS�. T :'21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient)S 22. jt-Cation:
9SSB'139 N 8-.q�SI1 G W ,,
6.Is(are)the well(s): 11PPermanent or ❑Temporary Signature of Certified Well ontractor 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 4VNo 15A 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 is 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 ifdierew(example-3@200'and @I00')
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,-NG27699-1617
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
�j�j air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: (q,4a Amount: 01-
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018