GW1-2021-06610_Well Construction - GW1_20211007

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1. ell Contractor Information:
14 WATER:ZONES
FROM TO DESCRIPTION
Well Contractor Name
b� rc �
_ i
NC Well Contractor Certification Number ISc°OUTER'-GASING'for multi=coded'w'ells.ORIiINER^if a hcable
Morgan Well & Pump I N C FRO i To
- DL4METER I THICKNESS MATERIAL
' ft. ti rL 61/8 'n sdr21 PVC
Company Name r
16::INNEWCASING'OR_TUBING eothermallclosed loo` ;S+
2.Well Construction Permit#: FROM TO DL41qETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM�E TO * �DL4METER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. !
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) g. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT,
*Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 fL bentonite poured
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation PACK(if if a hca`tile '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer _20i-DR1LLING'LOG attacti`addttioiial3heets'if neeess ?
FROM TO DESCRIPTION(color,ha ness soil/rock type,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remar s) 0 ft. ft.
G� r
4.Date Well(s)Completed: f —1'Z1- We11ID# ft. ft. ^ UX
5a.Well Location: ft. Albuo ft. I n-
C!,f P! ft. ft. \/1� e)T"
Facility/Owner Name Facility ID#(if applicable) ft. �t t
y?S`/ P0 fi�� n-� Cos►co�� ft. ft.
Physical Address,City,and Zip f t
�2n'REMARKS.,C(S�fr--s Wiz ;/y
�IQ 5
County Parcel Identification No.(PIN)
c`, " DNIR ��•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,
,00ne
ellatt//lloonggis sufficient) /y / 22.Cer' eafion: �` 'l �1 N '�O ,6sbh tI W J,C�T�-tom ! qdU
6.Is(are)the well(s): InPermanent or ❑Temporary Signature ofCert fled Well Contractor Date
By signing this form,I hereby certtfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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 wellidetails:
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: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifereni(example-3@200'and 2@100D
�j 24a. For All Wells: Original for trr to Division of Water Resources (DWR),
10.Static water level below top of casing: `y (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to IDWR,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
3-7 air-pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: /
13b.Disinfection type:�54r4-1°✓ Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018