GW1-2021-06636_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
_ ,.. . ._'
Well CtZct r ate _ ^ FROM ft TO DESCRIPTION
fOG��SC(��J ft ft E
NC Well Contractor Certification Number tt �>LQn �Qvl�Q� 15`OUTEIMASING for.'miiltt cased;we]Is"OR1Z4ER-if`a`Lcable
Morgan Well & Pump, I N C `r&311 ' Q�,NR FROM TO DL4METER TffiCKNESS MATERIAL
Company Name ^ ' l t`' t` 6 1/8 1° sdr21 JPVC` {
€`4:MV M CASING;ORTUBING eothermilclosedloo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
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.
Water Supply Well: FROM TO DIAMETER� SLOT SIZE THICKNESS MATERIAL
❑Agricultural bMunicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) @4esidential Water Supply(single) ft ft. ln•
❑Industrial/Commercial ❑Residential Water Supply(shared)
- t
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- bentonite poured
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft. ft. ,
❑Aquifer Recharge ❑Groundwater Remediation
19>`SANDlGRAVEL'P:ACIC`d a'-licalile Y<:..,>;
❑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) ❑Tracer �20;DRILLINGT OG'ittach idditiouilsheets if-uecess _FROM TO DESCRIPTION color,hardness,soil/rock ty type, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft. , tt ry
Q
4.Date Well(s)Completed: -\ - 1 Well ID# ft. ft 1 ^ �G�
Sa.Well Location: ft. ot>ft- '.Aq�1
ft. ft
V
acilityC/(Owner Name fe~� Facility ID#i(if applicable) ft. ft
1 I I T✓ ICA � �/�tt I c �111�yC�U+(
Physical Address,City,and Zip ft, ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/t/long is sufficient) 22.Ce • ation•
N ���•��2&bG� wZ
6.Is(are)the well(s): CJPermanent or ❑Temporary Signature of C teed Well Contracto Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or C1No 15A NCAC 02C.0100 or 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 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 construction info
construction,only 1 GW- is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You-may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7yo (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 00'and 2�a 100')
(7 C) (ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: 6 (in-) 24b.For Injection Wells:Copy to'DWR,Underground Injection Control(IUC)
o Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: f etary
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
i
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
2
13a.Yield(gpm) Method of test: air pressure Permit Program, 1611 MSC,Raleigh,NC 27699-1611
�J f
13b.Disinfection type: f O0JOW— Amount:
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018