GW1-2021-07822_Well Construction - GW1_20211102

Pritform,
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I
1.Well Contractor Information:
1 J (M 1 14:.WATER ZONES
FRO 0 DES POTION
Well Contractor Name f
ft ft
ft ft
NC Well Contractor Certification Number
15:OUTER CASING':(for multi cased wells)O$LII�R(if-alp lickble'
Morgan Well &Pump, Inc. FROM O I DIAMETER I THICKNESS MATERIAL
+1 ftI SO ft. 1 61/6/ In. I sd21 pvc
Company Name. I
(,V� 16:INNER CASING OR.T[IBIIVG �eothei�tasl dos8d-loo'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ll.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
: -
1 Water Su :.........: ::.. ,_:. ,::..,,.,....:..:-:-<. �...... ... . .:
pp y Well: FROM TO DIAMETER -I SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft ft in.
_il Geothermal(Heating/Cooling Supply) &esidential Water Supply(single) ft ft.
Industrial/Commercial DResidential Water Supply(shared)
'18r GROUT-
Irrigation 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 QGroundwater Remediation 19:SAND/GRAVEL PACK rf ii bcab
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_;Aquifer Test E3Stormwater Drainage ft ft
i Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) [3Tracer 20.DRnXING.LOG'itticli'additfon'kliheets.ifiiecessi' i
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Re�) FROM To I D CRIPTION(color,hardness,soilfrock type, rain size,etc.
1� V ft ft
4.Date Well(s)Completed: b' !'2` Well ID# ft, ft 4Af
Sa. Veil ocatio (�ft ft. `.
fL ft.
w •CK 7 a7 „J
Facility/Ow er Name 'A Facility ID#(if applicable)
ft ft
fL ft.
Physic Address,City,and Zip fL ft.
6�
7 � 4,�� :' -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) p 22.Certification:
��3y 19���-( N '—b�•�7 wCkV---7< .I �f 11
1.�
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Contract
� or 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 ONO with)SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standmds and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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,only 1 G4�/-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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3Q200'andd 2@100D construction to the following:
10.Static water level below top of casing: ! V (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 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: 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&Injection Wells: In addition to sending the form to
—171 the address(es) above, also submit Lone copy of this form within 30 days of
13b.Disinfection type: U9d&Ja+_ Amount: 1 )Ott, 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