GW1-2021-05639_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i
1.�Well
lCContractor Information:
�JY
i
i4:WATER ZONES <.
FROM TO DESCRIPTION
Well Contractor Name 21A9ft. fr.
alk
3 S� a JUL 2 '0 2021 ft ft
NC Well Contractor Certification Number
. Si OUTER CASING.for multi=cased,wells'OR_L•1NER if a" 's livable
Morgan Well& Pump, Inc. Inforrrlation processing Ur ITROM I TO DIAMETER I THICKNESS MATERIAL
+1 ft ft 61/8/ in' sdr11 pvc
Company Name .::.
16'INNER CASING OR TUBING' e'othei ma1.'clbsed=ldo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well:
PP Y FROM TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
J Geothermal(Heating/Cooling Supply) 69QZntial Water Supply(single) ft. ft in.
i Industrial/Commercial Residential Water Supply(shared) 18:GROUT.
__J Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fa 40 ft. bentonite poured
Monitoring Recovery
Injection Well: ft ft
_!Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEI`PACK if a `licabl'e
Aquifer Storage and Recovery Salinity Barrier FROM MATERIAL EMPLACEMENT METHOD
TO
J Aquifer Test 0 Stormwater Drainage fL ft
_i Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 1.i 20.DRDAING.LOG:fi ttacti'additional shi&6-if ueces`Sa
ex lain under#21 Remarks FROM To ESCRIPTION(color,hardness,soiurock a rain size,etc)
Geothermal(Heating/Cooling Rettrm) Other( ) ft ft
4.Date Well(s)Completed: U Well ID# 1Q,
ft
5a.Well Location:
1tr ft ft
Facility/Oner a Facility lD#(if applicable)
ft ft
w
?A�1 f4ank C ft ft
Physical Address,
City,and Zipft ft
\,Q��1� V�•L7- �;21:'REM:�,Rxs:-:.: ;_: i:.. _: _ .: .. .:;: .:_;
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. cation:
6.Is(are)the well(s)�ermanent or Temporary Signature of Certified PeCt,!,onar Date
By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or []No with 15A NCAC 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 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 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: I SUBMITTAL INSTRUCTIONS .
9.Total well depth below land surface: � �1 (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@100D construction to the following:
10.Static water level below top of casing: �, o (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 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: 1Y v 1 construction to the following:
(Le.auger,rotary,cable,direct push,etc.) I;
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: completion of well construction to ithe county health department of the county
where constructed. j
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016