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HomeMy WebLinkAboutGW1--07660_Well Construction - GW1_20231204 • WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: / J ~ .. �(J� •14:WATERZONESf:•r:; :�:c`�.:-=ti::*::'.�: •f:.. •.:.-.:. • •••• ...�•:•• •:.:.-•i.-•.::.:: - FROM TO DESCRIPTION Well Co/�,8 cto ame ft. ft. /�✓G ft ft. i ' NC Well Contractor Certification Number A' _15:iOUTER CASING.(for multi cssed:welle)OR LINER(if ap'livable)5'.'.- Morgan Well & Pump, I N C FROM TO DIAMETER :. THICKNESS MATERIAL ' 1 ft itt) ft. 61/8 in• SDR21 PVC Company Name • -16:INNERCASING'ORTUBING• eotliermal"closed-lao ' L. 2.Well Construction Permit#: -' �^ J ® v t FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. �- ft. ft. in- 3.Well Use(check well use): y�17::SCREEN .. ra ... .,.'s:..,. . ,t- .. Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ❑Agricultural , ❑Municipal/Public it ft in. ❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. M. . ' ❑Tndustrial/Commercial • ❑Residential Water Supply(shared) is 18:.GROUT'•'`:.••• .- +• ::'.,•:.r:::::.-:I;- --.... . .. ❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft' 20 ft bentonite poured ❑Monitoring ❑Recovery ft. ft. Injection Well: ft. it DAquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL'PACK(if applicable)::.:'•.::.;.;='?i•: •-.:'.'):::.0.:";,,'.-:'-':--:. ,.. OAquifer Storage and Recovery 0 Salinity Barrier FROM To MATERIAL• EMPLACEMENT METHOD ❑Aq uifer Test ❑Stormwater Drainage ft. ft. i ❑Experimental Technology 0 Subsidence Control ft. ft. DGeothernial(Closed Loop) ❑Tracer ::20:DRILL:INGLOG"(attachaddittonar'slieetiifneceaeary)•.:'•„' ;.'.:i:•:i:'. •'::•:' FROM TO DESCRIPTION(color,hardness,soillrocktype,grain size,etc.) ❑Geothermal(Heating/Cooling Return) q ❑Other(explain under#21 Remarks) 6� ft d ft. t n E/J _)��r • 4.Date Well(s)Completed:•-1-I V— i Well 1D# To ft. S ft. lot��(,,�^(/�ci I f+ 5a.Well Location: 7 5 ft /!S *ft AP /N le pt- fili6 M f.I U /J is ft. 3 2S ft. g I vie, V�J t.`44) Facility/Owner Name Facility ID#(if applicable). ft. ft ft. ft. r: 4 Physical Address,City,and Zip 21:RF.MARKA:r. . .... - ;':-:. ..;1 kf..:.):%' County Parcel Identification No.(PIN) • is;:u„ Tl 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: PO..` " '�'� (if well field,one lat/long is sufficient) 22.Certification: ��: /64 N — Z,7cOtie 6 w —/ _� Z /..-~ c 1, 6.Is(are)the well(s): OPermanent or DTemporary Signature of C. ..ed Well Contractor ! Date • By signing this form,I hereby cert((5i that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: ❑Yes or. !INo 15A NCAC 02C.0100 or 1SA 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: You may use the back of this page to provide additional well construction info 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary. drilled: I 24.SUBMITTAL INSTRUCTIONS /4 9.Total well depth below land surface: , (ft) ISubmit this GW-1 within 30 days of well completion per the following: For multiple wells list all depths if different(cramp e-3@200'aria 2@100) 3 ft 24a. For All Wells: Original form tb 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"+" 624b.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: rota'1 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 I FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA 13a.Yield(gpm) 51 Method of test: air pressure Permit Program,1611 MSC,Raleigh;NC 27699-1611 granulated chlorine / Z, S aZ 13b.Disinfection type: Amount: Form GW-1 .: North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018