GW1-2021-04074_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W Contractor M
�Rz
14..WATER ZONES
FROM TO DESCRIPTION,
Well Contra ame '�r•""F"" ..,.�
ft.
t ft. i
` j``A �F� C. � 2�2" ft fL
NC Well Contractor Certification Number 7 r �',ClA-Ulll"' 15::OUTER CASING(for•multi-cased'wells)OR LUiER if a' linable- .
Morgan Well & Pump, Inc. lt-,�It^aie+t i FROM TO DIAMETER' THICKNESS MATERIAL
ntr`.IS?c ,on +,
ft. ft. 61/8/ rn' sdr'21 pvc
Company Name .
16:INNER CASING OR TIIBING `e6tliermel dosed-lob
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits t.e,UIC,Couniv,State,Variance,etc.), ft ft. �•
3.Well Use(check well use): ft. ft �-
17.'SCRF.EN'::::
Water Supply Well: FROM TO DIAMETER •SLOT SIZE TRTCKNFSS MATERIAL
Agricultural QMunicipal/Public ft ft
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft g in.
i Industrial/Commercial Residential Water Supply(shared) 18.GRODT: ::'. ..:'
Irrigation FROM TO MATERIAL EMPL4,CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring ORecovery
Injection Well: ft, ft.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL'PACK if a 'licatile
Aquifer Storage and Recovery 0 Salinity Barrier- FROM TO MATERIAL EaMELACEMENT METHOD
I Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft ft.
Geothermal(Closed Loop) Tracer 20:'DRILLING.LOG'(ittabti'additidual'slieets if iieeeisa"j::_
Geothermal(Heating/Cooling Return) iOther(explain under#21 Remarks)ex FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,eta)
4.Date Well(s)Completed: Well ID# (� ft. C ft
ft
5a.Well Location: it
2
L ft. ft
D
Facility/Owner Name cility ID#(if applicable) ft
ft ft
y 6calddress,City,and i ftF
21.,REMARKS'.....County Parce Ojehtification No.(PIN)
5b.Latitude and longitude in decrees/minutes/seconds or decimal degrees:
(if well field,one IaUloan-gis sufficient) 22. ertificatio�`
6.Is(are)the well(s)JB or Temporary Si , e f Certified Well Contractor Da
sign g his form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or JoNo with IS CAC 02C.0100 or 15.4 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 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: 2-6 (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 a 2000'and 2Q100D construction to the following:
M 10.Static water level below top of casing: 0 (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,U derground 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!jni41� Amount: completion of well construction to ithe 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