GW1-2021-02627_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1.Well Co tractor Information: �'��
\U _
14.WATER ZONES
Well Contrac ame ,y,� FROM TO DESCRIPTION
_ 7 w\ O V ft ft.
-N 2Z \�\v tO�QiyO� ft. ft
NC Well Contractor Certification Number J ��Q �6G 15.OUTER CASING for multi-cssed.wells QR LINER if si licable
.Morgan Well &Pump, Inc. �� �3� FROM T DIAMETER THICENMS I MATERIAL
\ +1 ft 140 ft' 1 61/8/ in' sd2l pvc
Company Name
16 INNER CASING OR TUBING keothermal dlosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(11.UIC,County,State,Variance,etc.) ft It.
in.
3.Well Use(check well use): ft ft in.
11 SCREEN: "
ijlrrigation
ater Supply Well: FROM TO DIAMETER SLOT SIZE TATCKNESS MATERIAL
Agricultural DMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ftIndustrial/Commercial Residential Water Supply(shared) 18.GROUT FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
:. )Monitoring DRecovery ft. ft
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL'PACKCif applicable)
`
Aquifer Storage and Recovery E)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer 26.DRILLING LOG attachadditional sheets if ueceisa )
FROM TO DESCRIPTION(color,hardness,soil/rock type,gmin size,etc.)
Geothermal(Heating/Cooling
Returns) Other(explain under#21 Remarks) OD ft ft
4.Date Well(s)Completed: J ` Well ID# ft �j ft.
Sa WeJItLo n: ft ft
Facility/Owner Name Facility ID (if a plicable) ft ft.
r n l ft ft
4s ft ft
cal Address,City,and Zip
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
-3 . N b .92-59 W
6.Is(are)the weR(s)oPermanent or ElTemporary Signs of rtified Well Contractor Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: LlYes or QNo with 15A NCAC 02C.0100 or 15A NCAC 02C.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 421 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 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: (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@200'and 2@100D construction to the following:
10.Static water level below top of casing: (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 Infection Wells: In addition to sending the form to the address in 24a
Et �n✓ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f Y 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) 1 Z Method of test, air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ®Z/ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016