GW1-2021-02632_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Ccptracto n �tion:
IOU
i14.WATER ZONES .:. ...;. :..: . .. ::. _.,
Well Co actor 0 FROM TO DESCRIPTION
{IN ft ft.
IdaTIVIN ,�N 2 � 2021 ft ft
NC Well Contractor Certification Number
i .is:OIITER CASIN
Morgan Well &Pump, Inc. FROM G.for muIaDIA-csseii wells=OR LAVER tf a' IIeable
PCOOesS METER THICKNESS MATERIAL
9-1141011 +1 ft Oil ft 61/8/ in• sd,21 PVC
Company Name �111
l]G 16:'II9NER G OR T[TBING �:eotlt'ermal'clos'ed�lo 'r o
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits rz.e.UIC,County,State,Variance,etc.) ft ft In-
3.Well Use(check well use): ft ft in.
Water Supply Well: -..
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft in.
:]Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
_Industrial/Commercial [3Residential Water Supply(shared)
:18:GROUT., - - - -
IiTi atlOri FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring Recovery ft ft
Injection Well: ft ft
:')Aquifer Recharge Groundwater Remediation
� 19.SAND/GRAVEL`PACIC if a `licatile
Aquifer Storage and Recovery [3 Salinity Barrier FROM To I MATERIAL I EMPLACEMENT METHOD
_.Aquifer Test E3 Stormwater Drainage ft ft
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) OTracer 97b.DRTrTING.LOG{iittsctisdditionalstieets`ifuecess
FROM TO DESCRI TIO (colo,hardness,saiUrock type,grain size,etc
'Geothermal(Heating/Cooling Return) rM Other(explain under#21 Remarks) ft ft '
4.Date Well(s)Completed: Well ID# ftQii5
ft WK. `
a.Well Locatio vor�
ft ft.tk ft �/�om r e Facility ID#(if applicable) ft ft
t C. 1 eztr
p n � ft ft
��'111
cal Address,City,and Zip ft ft -
rc 1.�Y►� ^ 21:RF.MeRiCC
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) { Q 22.Cer' tion:
� N g4 W v M `��?
6.Is(are)the well(s)APermanent or Temporary Signatur Ce ed Well Contractor Dat
By sig this m,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or ON wizh 1 NCAC 02C.0100 or 15A 1VCAC 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#21 remarks section or an 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 of well
construction,only 1 GW-I 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:- 6.� /d' (ft-) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2�00'annd 2@100� construction t0 the following:
10.Static water level below top of casing: cam✓ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casino use•'+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
ll.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: l,N YI construction to the following:
(Le.auger,rotary,cable,direct push,etc.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL 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
Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection typ Amount: L► d completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016