GW1-2021-04288_Well Construction - GW1_20210901

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WEL14 CONSTRUCTION RECORD (GV�r 1� For Internal Use Only:
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1.Well ontractornInfatl ?�"
_ 1 I.. 02 14.WATER ZONES
Well Contractor Na e�aJ FROM ft TO DESCRiPT10N
�� oll ft ft.
NC Well Contractor Certification Number U �' r
15:.OUTER CASING(for multi-rased wells)OR LINER if a linable
Morgan Well & Pump, Inc. FROM To DIAMETER 'rHICKNESS MATERIAL
+1 ft, ft. 61/8/ in' sdr2l pvc
Company Name ft .
16:IlYNER G OR TCTBING eothecmal closed-loo
FROM TO DIAMETER ffi
.,.
2.Well Construction Permit#: (.1'� ��R'u� (�5a� TCKNESS MATERIAL
List all applicable well construction permits(i.e.WC,Cotntiv,State,Variance,etc)- ft. tn'
3.Well Use(check well use): ft. ft to
I Well: .17.'SCREEN'.:.:
Water Supply Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft-il
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft
Industrial/Commercial []Residential Water Supply(shared)
: .:
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. hentonite poured
Monitoring []Recovery ft . ft.
Injection Well:
ft. ft
!Aquifer Recharge []Groundwater Remediation
.19: 'SAND/GRAVEL-PACK if a llcable
)Aquifer Storage and Recovery []Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
_j Aquifer Test []Stormwater Drainage et ft.
i Experimental Technology []Subsidence Control ft. ft
Geothermal(Closed Loop) []Tracer 20.DRILL7NGLOG(attachladditidbal`s6eets if'n'eces's- )-
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etu
i Geothermal(Heating/Cooling Return) —I Other(explain under#21 Remarks) ft. Zo ft 1
a
4.Date Well(s)Completed: 12,1 1 Well ID# 2o ft. ft A
5aa..Well Location- � ft. MIL
-Y� o-S r y\e:,(0 ft.
Fa�cilittyy/Owner%IIme �yacility D>(if applicable) h-
P✓1� J��fd.Jf ti. � Aif' s•� N A��1•�1�"� ��tx�-1�, ft ft
Physical Address,City,and Zip ft ft
• .:.21.iRRMARKR:-._';.._•... .._:� ._ .., ...:.........::.........
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_ \tifrcation:
6.Is(are)the well(s)a Permanent or Temporary rgn,
Certified Well Contractor Date
e this form,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or fNo with 15A NCAC 01C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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 site details or well
construction,Qiil�y GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �y SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: . (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2 a@100D construction to the following:
M 10.Static water level below top of casing: "'Q15 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 in.) 24b.For Iniection 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: 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
(gP ) '� 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 typeC6 .V% Amount: al Y0 completion of well construction to the'county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016