GW1-2021-05522_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1ontractor Information:
14.R'ATER ZONES P a.
Well COnttaFt�'Name FROM TO �DESCRIPTION
g� (+_ V � pOg1 ft. ft I
"K' J�� h L L ft. ft
NC Well Contractor Certification Number n r (j tJl}jj
�r .,i1�.Bf t+'�Il j' r �(+§.�tfl•. r15;0iJTER CASING;(for',miilh casedwells'OR'LINER`.(if,-;a""`hcable) `
Morgan Well & Pump, I PdI ®>y SS t:O rt FROM TO DIAMETER THICKNESS MATERIAL
ft rt. 61/g tn• Sdr21 JPVC
Company Name -
j� 'f6.-1NNER CASING''OR-2 UBING'eother`maFclosed.loo =;
2.Well Construction Permit#: ��1- II Il FROM To DIAMETER TalcxivEss MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) rt. ft in.
3.Well Use(check well use): rt. ft in.
Water Su Well: 1,7SCREEN
Supply FROM TO DIAMETER LSLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaltPubbc ft ft in.
❑Geothermal(Heating/Cooling Supply) 4IResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) GROUT
01rri 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'SAND/GRAXEL`'PAfBC'rEa'licatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology El Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLINGIsOG attach`ai]djtional sheets if iiecess j.
FROM TO DESCRIP ON color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft
4.Date Well(s)Completed: GI Well ID# ft.54. ft.
ft. rt.
We Location: ,
Facility/Owner Name Facility 1D#(if applicable) � ft. c tUPC ,y t
2 C, ft. ft T III�
t �
Phys' 1 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/long is sufficient) 22.Cer' tion:
N W 11�/r 2 -- �?/---3
6.Is(are)the well(s): Permanent or ❑Temporary Signat o4fertified W tractor Dates ingorm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ¢No 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 Hinder#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 ac�r) GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You!may also attach additional pages if necessary.
drilled:' yy�� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z!li W (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
24a. For All Wells: Original form' to Division of Water Resources (DWR),
10.Static water level below top of casing: (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 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
/ air pressure Permit Program,1611 MSC,Raleigh,iNC 27699-1611
13a.Yield(gpm) � Method of test:
13b.Disinfection typ �t1 ✓ i Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018