GW1-2021-04273_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We C tractor Infoi
14.,WATERZONES
Well Cont;c�tor ame + (� FROM ft TO ft. DESCRIPTION.
ft ft.
NC Well Contractor Certification Number r a;•`(°tJ
15:;OUTER CASING(for multi-rased wells)OR LDQER if vable
Morgan Well & Pump, Inc. kpjotV"fin USiJ�G�ut 'O� FROM TO DIAMETER THICI4VESSa"'liMATERIAL
FJ +1 ft. ft. 61/8/ 'in' sd21 Pvc
Company Name hernial
2.Well Construction Permit#: 16:INNER CASING OR TUBING pot
r
n`�� closed-ldo
11 �. FROM TO DIAMETER THICI4`IFSS MATERIAL
List all applicable well construction permits(zle.UIC,County,State, Variance,etc.)- ft. ft in,
3.Well Use(check well use): ft ft in.
17.'SCREEN'.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural []Municipal/Public ft. ft. in.
__'Geothermal(Heating/Cooling Supply) IRResidential Water Supply(single) ft ft
I Industrial/Commercial Residential Wat&Supply(shared)
18.GROUT: :.'.
Irrigation FROM TO MATERAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. bentonite poured
'Monitoring ORecovery ft. ft
Injection Well:
ft ft
ni Aquifer Recharge rl Groundwater Remediation
19:SAND/GRAVEL'PACK if a "licatile
Aquifer Storage and Recovery ©I_'Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
J Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) [3Tracer 20.DRILLING+LOG(ittath additidfialslieets ifi e6eis- )'ss :•. %' :. :r :
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
-i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. A-© ft.
reJ
I .
4.Date Well(s)Completed: 4 �+ Well ID# �� ft 76 ft.
111
5a.Well Location: ft. ft
r\ ft. ft
•
Facii/liry/ty`�/ypO'fWK-11 ame {� y//Fa'elciliitty ID#(iifn/Lapplicable))q �(� �� ft y�0�j/5� ft b6
nh! 6 f�_ �' l A R 1 11�\ EI'-I S� _. `C�.ef,4 {,.,�
�05 ft ft }.j
Ph ical Address,City,and Zip 1�
21rRFMARKS::=.;..:.,; __..:,_ .._ � ..-._:..t•:..:.:..-'.,.•>..c'= -'�: -
ounty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3 t CJn N W `k n
6.Is(are)the well(s)APermanent or Temporary
ySigna „ of rtified Well Contractor e
s• zng h' form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or �No t' A AC 02C.0100 or 15A 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 thisform.
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
constractiX I GW-1 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:22p (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 e@200'and 2@100� construction t0 the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwaier 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: i('' r 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
I
(Bp ) air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield m Method of test: g
the address(es) above, also submit`one copy of this form within 30 days of
13b.Disinfection ty, ifyl(�s Amount: l\C�s= completion of well construction to!the county health department of the county
where constructed.
Form GW-I North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 2-22-2016