GW1-2021-06628_Well Construction - GW1_20211007

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ell Contractor Inf rmation:
14:W:ATER'ZONES ,x_ r':s, `
Well Contractor Name T ROM TO T DESCRIPTION
it. ft.
NC Well Contractor Certification Number 3tt0
^'�+ ��' Q��a ,15s`�OU3'ER`CASING:for,'mulhcasedwens;OR;I:`Il�tER-`if�a"'lic'able:--:, - -_
Morgan Well & Pump, INC V C FROM TO DL4METER THICKNESS MATERIAL
42 ft. b ft 61/8 '° Sdr21 PVC
Company Name Q Y_ Y
a16 INN_ER,CASING:OR:TiTBING`^'eothermal'closeddoo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fL in.
:171 SCREEN z_
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothennal(Heating/Cooling Supply) 1OResldential Water Supply(single) ft. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) •18GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO I MATERIAL' N EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0. ft' 20 ft bentonite poured
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
,19fSAND/GRXV.EL..PXCK'tf
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD..
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothennal(Closed Loop) ❑Tracer i,"20 bR1LL1NG;LOG.(attacti;addthonal;"sheets
FROM TO DESCRIPTION color,hardness soil/rock type,gmin size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(ex lain under#21 Remarks) tL
4.Date Well(s)Completed: J Well ID# S fL p fL Ire
5a.Well Location: Q ft.
6 ft•
/yq OtC C V 1 I ``� PS d ft. (PLE ft-
Facility/Owner Name `' Facility ID#(ifapplicable) p � O�y ft. ft- �,�
2 o G KS2r Ir1 s r 7 �i J ft. ft.
Physical Address,City,and Zip ft. ft.
J ✓����� 15'97 7ly—lir�6 RF.MARRS €.
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.C leafion:
328( "Z N
6.Is(are)the wetl(s):Werinanent or ❑Temporary Si tune of ell Contracto Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ANo 15,4 NCAC 01C.0100 m•15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the we i 11 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:' Z 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '5dV (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdperent(example-3Q200'and 2Q100')
y24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: / (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to0WR,Underground Injection Control(IUC)
11.Borehole diameter: 6 (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
�[ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) V 2 Method of test: a I r p reS S u re
13b.Disinfection type: Amount: /Zd2L
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources! Revised 6-6-2018