GW1-2021-02630_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
MOT
on: l.0�
�'✓, 14.WATER ZONES
Well Co tract r N me FROM TO DESCR1PT10N
n\3 ft ft
cam$\'A ft ft
NC Well Connector Certification Number �t�10��Cc'eC;On 15.OUTER CASING for multi-cased wells OR LINER if sCp livable
Morgan Well&Pump, Inc. �� ' 0���J FROM I TO DIAMETER THICKNESS MATERIAL
+1 ft ft 6 1/8/ in' sd,21 pvc
Company Name
-2z j 16:-OiNER C7ASING OR TUBING e'othermal closed-loo
2.Well Construction Permit#: ✓ FROM TO DIAMMF••TER TaICNN SS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) fL ft i�•
3.Well Use(check well use): ft Ift in.
IT SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural C]MunicipaUPublic ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft
_)Industrial/Commercial Residential Water Supply(shared) 18:GROUT
—)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft 20 ft. bentonite poured
Monitoring QRecovery ft. ft
Injection Well: ft ft.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL ACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft ft
Experimental Technology EJ Subsidence Control ft ft.
_ Geothermal(Closed Loop) Tracer 20.DRILLING.LOG attach additional Wets if n&es'sa
FROM TO DESCRIPTION(wtor,hardness,soil/rock p e, rain size,etc.)
i Geothermal(HeatinglCooling Return) _'Other(explain under#21 Remarks) � ft ft
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4.Date Well(s)Completed Well ID# ft 4ft.
5a.Well Loca'on: S ftCes ft+ ft ft 10
VV
Facility/Owner Nar& Facility ID#(if applicable) ft ft.
utit va W,�-17
ft ft
Physical Address ', ,and Zip ft ft —
:21;'RRMARKS
Mn
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22. t [cation:
6.Is(are)the well(s)C)Permanent orOTemporary Si a Certified Well Contractor "Da
ring this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or []No 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 ofthe copy 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 site details or well
construction,only i 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: 300 (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'ami 2@100� construction to the following:
10.Static water level below top of casing: AO (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 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: 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) L4 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: /ZOz 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