GW1-2021-04076_Well Construction - GW1_20210901

I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name - f
3S13L � lt� � 2O�11- ft
NC Well Contractor Certification Number r nr�`;(!r�i)ill$ 15;OUTER CASING for.multi-cased wells OR LINER if a"licable
,•�,�'�;'��:T�t��'n FROM I TO DIAMETER THICKNESS MATERIAL
Morgan Well & Pump, Inc.
�\a +1 ft 14q ft- 1 61/8/ in' sd,21 pvc
Company Name „^ ^
Z^ /�1 16:1NNER CA G OR TUBING `e6tkermal cCosed-ldd
2.Well Construction Permit#: V FROM To DIAMETER THICIL�Ess MATERIAL.
List all applicable well construction permits ri.e.UIC,Cou nv,State,Variance,etc.) ft in.ft
3.Well Use(check well use): ft. ft in.
=17:SCREEN':::.:..;.::'.• . ..-_...._:,: ::::;_.::. . - ,.::.
Water Supply Well: FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft
:]Geothermal(Heating/Cooling Supply) DRIesidential Water Supply(single) ft. ft �•
hldustriaUCommercialResidential Water Supply(shared) 18:GROUT: ;.
I hri ation FROM TO MATERIAL . 'EMPLACEMENT METHOD&_AMOUNT
Non-Water Supply Well: 0 ft. 20 ft bentonite poured
Monitoring Recovery ft. ft
Injection Well: ft ft.
_i Aquifer Recharge Groundwater Remediation
.19.SAND/GRAVEL-PACK if i 'l 6bl :
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology)Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer 20::DRnlING.LOG(ittsdi'additi6hal stieets.if necess a')'-
FROM TO DESCRIPTION(color,hardn s,soiUrock type,gain size,etc)
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) ft. O ft_ n )
4.Date Well(s)Completed: v I Well ID# ft
ft ft
Sa.Well Location: ���`���
ft. ft
c tl
Faciillity/Owner Names M rI Facility EA(if appliclablle�)�� ft. ft ysical Address,City,and Zip 2� ( � ft ft
l 1 u
`21:I2EMARKS '.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W o?
6.Is(are)the wells) rmanent or OTemporary Signature of Certified Well Gba4idctor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: a<as or ©I No with 15A NCAC 02C.0100 or ISA 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 omier.
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,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this firm within 30 days of completion of well
For multiple wells list all depths if different(example-3Q2 0'and 2@1001 construction to the following:
10.Static water level below top of casing: L4 (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: 1 y� 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) A Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
j the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 12o completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016