GW1-2021-02634_Well Construction - GW1_20210620

P.�in�Forme
WELL CONSTRUCTION RECORD (GW-1) �, For Internal Use Only:
1.Well C tractor ma'o�� �,� �
14.WATER ZONES - .:. _..
OM TO DESCRIPTION
Well trac r m ``A\
ft ft.
B t\On ft ft.
NC Well Contractor Certification Number \`,� CJ C'
(r 15EOUTER CASING formulti cased'wells}OR LIIVER if a heable
Morgan Well& Pump, Inc. FROM TO DIAMETER THIC/SNFSS MATERIAL
+1 ft. I ft' 61/8/ rn sd21 pvc
Company Name
16 INNER CASING OR TIIBING` 'eothermal:rlased -
2.Well Construction Permit#: FROM TO DIAMETER THICENESS ,MATERIAL
List all applicable well construction permits(i.e. WC,County,State,Variance,etc.)- R• ft in.
3.Well Use(check well use): ft. ft in.
M'SCREEN .::...
Water Supply PP Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'ilAgricultural DMunicipal/Public ft ft in.
:)Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) ft ft
Industrial/Commercial []Residential Water Supply(shared)
�1181 GRO1TT.. : - -Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft bentonite poured
:—')Monitoring QRecovery ft ft.
Injection Well: ft ft
__Aquifer Recharge [)Groundwater Remediation
19.SAND/GRAVEL'PAC'K rf a`Ucabl'6 .:':: ::
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) [3TracerZS.DRIISING.LOG{attadi'additiiialslieets=ffnecess
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type rain size,etc
o 11D ft
4.Date Well(s)Completed: Well ID# 0 o ft D ft ,
ft Lt or ft
5a.Well Location:
ft �ft
4 F ility/�n e �� /1�FacilityID# fapplicable) ft ft
0 (� ft ft
al Address,City sand Zip It,
ft ft
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Q 1541 q 22.C fion:
N t;• W
6.Is(are)the well(s) Permanent or OTemporary Sign1ANZ02C.0100
ed Contactor Date
By sm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No with or ISA 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 a wer.
repair under 421 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-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: 6J�ti (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-33@2200'and 2@1001 construction to the following:
10.Static water level below top of casing: I (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 ( 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:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY SWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) i 71 Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
g the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type Amount: g fr 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