GW1-2021-02608_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well C or Informati
AA L4 OJA- '14.WATER ZONES
Well Con eto am FROM TO DESCRIPTION
ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Wells OR LINER if a" lieable
Morgan Well & Pump, Inc. FROM TO DIAMETER THICKINESS MATERIAL
+1 ft. ft. 61/6/ In• sdr2l pvc
Company Name
16INNER CASINGORTUBING _eotliermal'd6ied46&d
2.Well Construction Permit#: ��� FROM TO DIAMETER THICKNESS MATRRisi.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. In.
3.Well Use(check well use): ft. ft in.
IN.
ater Supply Well: 17 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft.
ndustrial/Commercial Residential Water Supply(shared) 18:GROUT
rri ation FROM TO MATERIAL EMPLSCEMENTMETHOD&AMOUNT
n-Water Supply Well: 0 ft- 20 ft. bentonite poured
Monitoring Recovery ft, ft.
ection Well: fL ft.
quifer Recharge Groundwater Remediation
.19.SAND/GRAVEL PACK a licable quifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHODquifer Test Stormwater Drainage ft ft.
xperimental Technology Subsidence Control ft. fteothermal(Closed Loop) E Tracer 26."DRILLING.LOG_attach"additidual alieets if necessaeothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/racktype, rain size,etc.)
b ft- tt. �,,��, ►r
4.Date Well(s)Completed: Well ID# v ft r ft
Sft rM ft
STa.Well Loca�ti�on1 a
vt,
Facility/Owner Name I Facility ID#(if applicable) ft. fL
Bair p(—A& Lin, CLrl d k N(, Z$705 ft ft
by'cal Address,City,and Zip A ft ft s"
Jaril' ��' •� 1� `:21c REMARKS -
County Parcel Identification No.(PM
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Processing Unit
(ifwell field,one lattlong is sufficient) Q 22.C cation: 0WR Secron
�r :�L)
6.Is(are)the well(s)aPermanent or Temporary Signatur f ertifiedWell Contractor Date
n t 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 MNo wit 15AN 01C.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 oWMer.
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: ZJe0 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: -5 (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 (in.) 24b.For Infection 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: Air 6+0'/LA 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: Amount: I 0 bZ 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