GW1-2021-06597_Well Construction - GW1_20211007

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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Well Contracto a ft
FROM TO DESCRIPTION
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M� �O ��n i
NC Well Contractor Certification Number �10� t;��' 15r;OUTER':6ASING'fofjgtt-cased'wells"ORI INER'if:a hcable s=
Morgan Well & Pump I N&r-"` OWN FROM TO DIAMETER TffiCKNESS MATERIAL
' + ft. 2—ft 6 1/8 to Sdr21 IPVC
Company Name
�93®� .16:iINNER:GASWG:OR:TUBING, eotherinaL"closed loo'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits 0.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM�E TO DIAMETER i SLOT SIZE THICKNESS (+MATERIAL,µ
❑Agricultural ❑Municipal/Public ft ft. in. 1
❑Geothermal(Heating/Cooling Supply) *Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) ->
.18:GROUT
❑Iri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation '
19.[SAND/GRA, EL PACK tf a` licatile
❑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;DRm':r:rvGE0G atta6radditi6dals1feetslfnecessa
FROM TO DESCRIPTION color,hardness,soil/rock type,.._ in size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. L 0 ft Y6 d%r+
4.Date Well(s)Completed: Well ID# � ft. ;145 ft
Well Location: 6 ft. ft ��� ` Y ,
���l - ft. ft J
Facility/OwnerName Facility
;�.,#(ifabppli/c�a�b�le) j� i s�� ft. i ft
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cal 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 Iat/long is sufficient) 22.C cation: ,�
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6.Is(are)the well(s): SPermanent or ❑Temporary Sig na o ertified Well Contractor Da
BI o wing form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 4Wo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Iflhis 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: p� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: GM (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Qa 1001
5 24a. For All Wells: Original form to Division of Water Resources ('DWR),
10.Static water level below top of casing: 4 (ft) 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)
Program,1636 MSC,Raleigh,NC 2I 699-1636
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
13a.Yield(gpm) Method of test:
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection typ Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources a Revised 6-6-2018