GW1-2021-07800_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Contractor Information: I
14:.WATER ZONFS<.'. -
101� l ., : . ..... . : . .
FROM TO DESCRIPTION
Well CoGhactorName
'/�1 A r�(� V ft ft.
aS`�e `�al ft ft
NC Well Contractor Certification Number \`t �t,r�e
J O� 15:OUTER CASING,(foc multi=es edlwells)OR LINER if'a livable
Morgan Well &Pump, Inc. �;�r,'tf1 t �o',;l' FROM TO DIAMETERTffiCKNESS MATERIAL
r .
+t ft ft 6 1l8/ in. sd21 PVC
Company Name ,... : . :. _
J��Q q��fj� Q 16:INNER CASING OR TUBING"�eiithernral closed..-loti' .
2.Well Construction Permit#:II'`�I�'U-L6 —��l 8 FROM To I DIAMETER I THICICNESS MATERIAL
List all applicable well co»sAuction permits(ie.UIC,County,State,Variance,etc) ft. ft in.
3.Well Use(check well use): ft. ft in.
-
Water Supply Well: :.�=�_:::.::..(..:..;:'i;.-=:;.. -`;�:;._. ..: .
FROM TO DIAMETER SLOT SIZE THiCKNFSS MATERIAL
:)AgriculturalMunicipal/Public ft ft in. I
_i Geothermal(Heating/Cooling Supply) jgResidential Water Supply(single) ft ft I in.
I Industrial/Commercial DResidential Water Supply(shared) 18:GROUT
(Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft 20 ft. bentonite poured
_'.Monitoring Recovery ft. ft.
Injection Well:
ft ft 3_-I Aquifer Recharge Groundwater Remediation
:.
;'19:SANDlGRAVEL'PACK if a'livable
'Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_i Aquifer Test [3Stormwater Drainage ft ft.,
Experimental Technology Subsidence Control ft ft
EGeothermal
Geothermal(Closed Loop) Tracer 20.DRII.LIlVG.LOG'(ittiili- dditionaliViets".jfri 'eceis' -:`(Heating/Cooling Return) Other(explain under#21 Remarks). FROM TO D CRIP ION color,Hardness,soillrock ty rain size,etc.
ft. R �.
4.Date Wells)Completed: /0�J Well ID# Q ft. Q ft r&&�% �-
Sa.Well Location: ft R
�n I�� �t�[� s ft t5D fL C/� �. ri�q•
Facility/Owner Name11 Facility ID#(if applicable) ft. fr
Physical Address,City,and Zip' ft ft
C4-NA-6e-- • Vs3171-20V0
County •Parcel Identification No.(PDT)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,on ng is sufficient)N �-T1' I g" /146 W 22.C tification:
nJ (��fQ G7 7 Cac'k�,v l3 ?vZl
6.Is(are)the well(s)dPermanent or OTemporary Signature of Certified Well Contractor 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: []Yes or JANo with 15A NCAC 02C.0100 or 15-A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction iriformation and explain the nature ofthe copy of this record has been provided to the'well owner.
repair under 421 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 1(,rW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /J SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2� (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'V�-
00� construction to the following:
10.Static water level below top of casing: (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
��,,J above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ; r "r rfi� 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
i "
13a.Yield(gpm) V Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sendingthe form to
Q� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: f SR..'I'v Amount: • OZ completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016