GW1-2021-02526_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD GW- ® For Internal Use Only:
ontracto�mation:
14.WATER ZONES -
FROM TO DESCRIPTION
Well Connt2-2-
ra^ct7 Name \`\ O�erySO ft. ft.
SA"- — ,V\'���Q��2,G�' ft. ft
NC Well Contractor Certification Number nJ. T�¢ 15:OUTER CASING for multi cased wells OIFLIlVER if a" licsble J
Morgan Well&Pump, Inc. :,��' � FROM To DIAMETER THICKNESS MATERL,
+1 f. I ft 61/8/ in' I sd21 pvc
Company Name
J �I FROM
INNER C G OR TOB AM `eother mal closed ES :
2.Well Construction Permit#: D FROM TO DIAMETER TffiCKNSS MATERIAL
List all applicable well construction permits .e.UIC,Cow y,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: FROMErTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft ft. in.
_'I Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) fL ft in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT.
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring DRecovery ft. ft.
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK Cif licable
Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft
_ Experimental Technology Subsidence Control ft ft
_ Geothermal(Closed Loop) MTracer $21 DRII LING LOG:ittac3 additional slieets if uecessa
FROM I To (color,hardness,soiUrock arain size,etc.
Geothermal(Heatin .Coolie Return)
) Other(explain under#21 Remarks) DESCRI T[
a ft ft rid dw-v
4.Date Well(s)Completed: Well ID# , b ft It.
5a.Well Lo do ' �d ft C> ft
Oeyy, 6-YOW ft f.
Facility/Owner Name Facility ID#(if applicable) 0ft ft
b711 4): E",S54 hK 6-T t o ft e
ic�allAAddress,C t
City,and Zip f
jjj fr.
� '2L REMARKS _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) �j 22.C cation•
N —1 6.r759(0 W �� I
6.Is(are)the well(s)J3 Permanent or 13Temporary Si a ertified Well Contractor Dat ig i is form,I hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or E3No with 15 I CAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back oflhis 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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 12 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 00'and 2Q100 construction to the following:
10.Static water level below top of casing: Sb (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �r r'w4 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
a the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016