GW1-2021-02336_Well Construction - GW1_20210527

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Con actor Information: C
1-14.:WATER ZONES
FROM TO DESCRIPTION
Well Co tra or ame
ft ft.
ft ft I
NC Well Contractor Certification Number 15 OUTER CASING(for multi-cased wells)OR LINER(if ip livable
Morgan Well &Pump, Inc. FROM I TO DIAMETER THICKNESS MATERIAL
/��
+1 ft. ft 61/S/ in. sdr21 pvc
Company Name Af)3 6055�
16.INNER C G OR TUBING' eothermal closed-loo
2.Well Construction Permit#: FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits C.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROM AT'SCRF.FNTO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public ft. ft in. 1
_i Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) ft ft in.
i Industrial/Commercial Residential Water Supply(shared)
18:GROUT.
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
_:Monitoring ORecovery ft ft
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a 'bca' ble - ..
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
_ Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer w 20.DR1I LIlVG..LOG'(att�ch`sdditional sb'bets if ueceisa )''::
FROM To DESCRIPTIN(color,hardness,sosoil/rock ;`..
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) type, rain size etc.)
ft 26 ft 'f
4.Date Well(s)Completed:E I We11ID# ft ft.
5Vyell Location Sft. �c� ft. Sce n
inks
FFaci�lliity/Owner.Name FacilityID#(if a(plicable) ft l� ft ; F
115
Pi„g%iaa;Addr ss,Ci ,and Zip ft.
2L-REMARKS
County Parcel Identification No.(PIN) 1V1�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,oonne llat/long is sufficient) �y
L 22.C f(cation
, 5 1 N — C .71702— W 511, Lz
6.Is(are)the well(s)fa Permanent or Temporary S' of Certified Well Contractor Date
By signing this form,1 her•ebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or [PNo with ISA NCAC 02C.0100 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 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-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: J!J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dil/erent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: &0 (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: 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 Sup IV&Injection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount: (7 completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 .