GW1-2021-04073_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I/1 S ��UGyr�
14.WATER'ZONES
FROM TO DESCRIPTION
Well Contractor Name Vz&1t.
)W ft
3S�a ft ft.
i
NC Well Contractor Certification Number
15 OUTER CASING(foe multi-cased wells OR LIIVER if a livable)• :.: ;•_: :
Morgan Well &Pump, Inc. FROM To I DIAMETER THICKNESS MATERIAL
+1 ft ft. 6 Val in' sd,21 pvc
Company Name ^ ^ _ ^ - -:_:,:
'/�jr� 'LJ OS/I 16:INIVER.CASING OR TUBING'Meothe'rmal closed-loo ;
2.Well Construction Permit#: FROM TO DIAMETER TffiCKNESs MATERIAL
List all applicable well construction permits rz.e.UIC,County,Stale,Volance,etc.) M ft in.
3.Well Use(check well use): ft ft. �•
Water Supply Well: FROM C-REENTO DIAMETER SLOT SIZE 77=
Agricultural QMunicipaVPublic ft ft in.
_;Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft
I Industrial/Commercial [3Residential Water Supply(shared)
GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring DRecovery ft. ft.
Injection Well:
ft ft.
__!Aquifer Recharge []Groundwater Remediation
19:SAND/GRAVEL-PACK ff a'li6lile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
J Experimental Technology Subsidence Control ft ft
_ Geothermal(Closed Loop) OTracer 20::DRILLING.LOG(attacb'additi6ual slieets.if recess- •)'-': = „"
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
10 ft. W ft.
4.Date Well(s)Completed: Well ID# ft ft
5a.Well Location: ft ft.
o ft. ft e)� 1 s 9 m
r I 1 1v`/b ��..
Facility/Owner Name 2/� Facility M#(if applicable)
Q (� ft ft
hn `VI c �LC)I�7.112 ft ft. ti n
thysical Address,City,and Zip ftt, "IrJLpr„��,../•. � =21:REMARKS" - r.3l:�i � x� ::�;>:•?,�r�i1,`i;= - - - -
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.Certification:
6.Is(are)the well(s) manent or OTemporary Si
.., ergnature of Certified Well Contra Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or To11*� with 15A NCAC 01C.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 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: I '' nn SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �J.� (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@200'and @I00D construction to the following:
10.Static water level below top of casing: O (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in.
24b.For Infection 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: 1 F i 1 l/L 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
13a.Yield(gpm) ' Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
` ,^, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: to � 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