GW1-2021-04079_Well Construction - GW1_20210901

i
i ,ryPrint Form:
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Co tractor Info tto
14-WATER ZONES
;.-- any..,- FROM TO DESCRIPTION
Well C mrac r Name a .u., fL ft.
i
'� 1 2021 ft ft
Sty l'•
C Well Contractor Certification Number 15::OUTER CASING(foi multi-cased wells)OR LINER if a'livable
Morgan Well &Pump, Inc. ,,,.„aticn�''" FROM TO DIAMETER TffiCKNESS MATERIAL `
�it1�r1" r C,r_. +1 ft in. sd21 pvc
Company Name
FROM TO DIAMETERhecin's.1 clo'sed-ES "'
1 .16:"INNER CAS G OR TQBING g�eot � �. - •�"�
2.Well Construction Permit#: 1 / THIcxNFss MATEIUAI.
ft ft in.
List all applicable well construction permits i.e.UIC,County,State,Variance,etc.)
ft. fL 3.Well Use(check well use): in.
117.'SCREEN'.-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural r.lMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) llResidential Water Supply(single) ft. fL
_i Industrial/Commercial Residential Watei•Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring QRecovery ft. ft.
Injection Well: ft. ft
J.Aquifer Recharge I Groundwater Remediation
19:SANDlGRAVEI,'PACK if a 'licatile '
rilAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMELACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
J Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20:DRILLING..LOG'Ottacli`additidnal'il eets if i eceisa")... 1>' :. : : '.. ``.'•
FROM TO ,DESCRIPTION(color,hardness,soil/rock type,gmin size,etc.)
Geothermal(Heating/CooliCn�g'Return) _i Other(explain under#21 Remarks) ft.
4.Date Well(s)Completed: + M z I Well ID#
5a.Well Location: ft. r' ft
ft. ft.
r
Facility/Owner Name Facility ID#(if applicable)
ft ft
" { ft ft
ft ft.
hys•al Address,City,and Zip
o fy Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one
ellat/long is sufficient) fig , /y 22. ertification:
s 1 ,lJ 1 N DI']OW0 W 11
6.Is(are)the well(s)aPermanent or OTemporary Sifatukof Certified Well Contractor D e
sig r this farm,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [I Yes or MNo ith 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 owwer.
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, iW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
I
drilled: Ilk SUBMITTAL INSTRUCTIONS
9.Total well dep rtr below land surface: go A) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'nand 2Q100D construction to the following:
` 10.Static water level below top of casing: J 01 (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 (i .) 24b.For Injection 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
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
2 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type Amount: completion of well construction toi 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