GW1-2021-02631_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W Contractor Information: -!
t,.y 14.WATER ZONES
FROM TO DESCRIPTION
Well Contra
Name ,` 2021 IL ft
1k;i 'A ��1v O L Vlllt ft. ft.
NC Well Contractor Certification Number p�© gg�ng .15.OUTER CASING for could-cased wells OR LINER if 211 licable
Morgan Well &Pump, Inc. �Of0Sr��t�� comet t10� FROM TO DIAMETER THICKNESS MATERIAL
O�NR +1 ft. ft 61/81 in. sdr21 pvc
Company Name
16:INNER CASING OR TUBING keotliermal closed-Ido
2.Well Construction Permit#:�� > 1�.(�o A , FROM TO DIAMETER TMCKNESS MATERIAL
List all applicable well construction permits(i.e.0C,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft. ft in
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TffiCKNESS MATERIAL
Agricultural E)Municipal/Public % ft. in.
Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18:GROUT _
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft- bentonite poured
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
JFxperimental
uifer Recharge Groundwater Remediation
19:SAND/GRAVEf.PACK tf a liiable
uifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMELACEMENTMETHOD
uifer Test Stormwater Drainage ft. ft.
Technology Subsidence Control ft. ft.
othermal(Closed Loop) Tracer 26.DRILLINGLOG_(,ittcli-additional sheets ifaccess )
FROM TO DESCRIPTION(color hardness,soil/rock e, in size,Nu)
othermal(Heatin .Coolie Return) _ Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: Well ID# tcs ft ft. `
5 Well LMQ
' ft ft
Ybe
(Facility Owner N '`` ,..� Facility ID#(if applicable) VV
Ca fL ��ft
Rlyl� RLJ_u� L, K ��0 fL ft.
sicaI Address,City,and Zip ft ft.
'21.REMARKS'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweh field,one l�at/lllo'nng is sufficient) p 22.Ce ' ati n•
ra .���JA✓ _N (�6447-� W
6.Is(are)the well(s)MPermanent or Temporary Signam fVrtdWeU Contractor Date
th ,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ENo with 15A NCAC 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 of this form.
23.Site diagram or additional well details:
8.For Geopro e/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
constmC CIO
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: 200 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-33@200'and 2Q100') construction to the following:
10.Static water level below top of casing: ..T✓ (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 A (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
A. 0above,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) 0 Method of test- air pressure 24c.For Water Supply&Iniection 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: (4'1 He� Amount: O7i 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