GW1-2021-02629_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Infol•ma'on: y�
14.WATER ZONES
Well Con cto Name FROM r DESCRIPTION
�ll ft it
ft. it
NC Well Contractor Certification Number
Una
�y �$$1n9 15:OUTER CASING for mnlased.wells�OR LUNER
Morgan Well &Pump, Inc. 1nt��r`,3tton rr� pn FROM To DIAMETER THICKNESS MATERIAI.
1 ...nIR Sf3 +1 fL ft 61/8/ in' sdr21 pvc
Company Name -
16:INNERCASING OR TUBING``eotberuial.c[osed-ldo :':. :.... .;;. ...
2.Well Construction Permit 4: �9 l FROM TO DIAMETER TIIICIINESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cotnity,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft in•
Water Supply Well: 17 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft ft In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in,
:]Industrial/Commercial 13Residential Water Supply(shared) 18:GROUT
1tri ation FROM - TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft Y0 ft. bentonite poured
Monitoring DRecovery ft. ft.
Injection Well:
f4 ft
Aquifer Recharge 0 Groundwater Remediation
19:SAND/GRAVEI,PACK d a litable
_ Aquifer Storage and Recovery n Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft
EGeothermal(Closed Loop) Tracer $26.DRILLING.LOG(Attach additional sheets if necessa
Geothermal(Heating/Cooling Retum) M Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,gmin size,etc)
b ft ft r
4.Date Well(s)Completed: Well ID# }O ft. 30 ft. bmzK Ir"-
5a.Well Locatio ft. ft.
a 3 ft S -(--Oct
Facility/Owner Name Facility ID#(if applicable) ft ft.
It. ft
sisal Address,City,and Zip ft. ft —
_ � -,21"REMARKS
County ParcelIdennfication No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat//loong is sufficient) n
tification•
3,5,I O N Sb.YD J W
6.Is(are)the well(s) O Permanent or OTemporary M'i.-
f Certified Well Contractor Datthis form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or nNo 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#11 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 ifdifferent(example 3(200'and 2(Qa 1001 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 casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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: l,r U 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
(gp ) air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield m Method of test: g
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: m 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