GW1-2021-02633_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
1.Well actor InkapaRA04 �
14.WATERZONF.S _
Well o Name FROM TO DESCRIPTION
202� fL ft.
1 N2 �
y fL ft
NC Well Contractor Certification Number U�1
ulti
Morgan Well &Pump, Inc. ^1Ct�:ionprse pn� FR MD RC OSING.ft DIAMETER Oz ci�vF s a' uMATERIAL
J
Company Name �j ' U" +1 fL ft
61181 in' sdr2l pvc
2✓r,35 16 IIVIVER CASING OR T[JB11VG` 'eothermal.`elosed loo i::: .':-
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(,e.MC,Comity,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural r!)Municipal/Public ft. ft. in.
_'3 Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) ft ft in,
Industrial/Commercial Residential Water Supply(shared) _ __
:`18:GROUP..:.:. -
Iiri atiOII FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 H- bentonite poured
_'Monitoring Recovery ft. fL
Injection Well:
ft. ft
Aquifer Recharge OGroundwater Remediation
19:SANDIGRAVI;L`PACK if a Ucabla
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
_ Aquifer Test Stormwater Drainage ft ft
_ Experimental Technology Subsidence Control fL IL
Geothermal(Closed Loop) 13Tracer Zb.DRILI IIVG.LOG(a"ttsdi'6dditional slieetsaf iiecessa )
Geothermal(Heating/Cooling Coolie Return) f Oth bi_ er FROM -TO DESCRI TI (color,hardness,soil/rock a rain size,etc
(H g/ g ) (explain under#21 Remarks)
f o ft '�o ft
4.Date Well(s)Completed: �r Well ID# Zo ft st> ft rvwo
ft IL
d
S�anW`e,II Location: ��(' /�
'W\'Jl wk K] V ft -&20ft
Facility/Owner Name Facility lD#(ifapplic/abl)e)�y ft ft
O MCl
/(J�"/ ft ft
cat Address,City,and Zip 1/ { h n
'-21aRFMARKC-'.:'z:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) (� 22.Cer' tion•
-S5-� N` '543g W �j�- 7-2
6.Is(are)the well(s)opermanent or ElTemporary Sig45A
fC 'fied We ' ontractor Date
By farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or *NO wiz C 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 ofthis 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 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: ?100 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,$erent(example-3Q20(0'and 2@1001 construction to the following:
10.Static water level below top of casing: 'v (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 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� �t 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) 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. 1 Amount: q 02. 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