GW1-2021-07832_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
CWGIs ontractor Information::
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft \16 ft
ft ft
NC Well Contractor Certification Number 15:OUTER CASING:(for multi=rased wells)OItLIlJER if'a livable
Morgan Well &Pump, Inc. FROM To DIAMETER TfficrtrEss MATERIAL
+1 ft O ft 61/8/ in' sd21 pvc
Company Name /V`J 16:INNER CASING OR TIIBIlVG eotheivtal closed loo r
2.Well Const;'UCtion Permit#: I FROM TO I DIAMETER I THICENESS MATERIAL
List all applica a well construction permits(i.e.WC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ' fc ft in.
17:'SCREEN'.: . .<.
Water Supply Well: :...::::.,<.;.. .r..A
PP Y FROM TO DiAMET'ER ' SLOT SIZE TTIiCKNFSS MATERIAL
Agricultural r—IMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) , esidential Water Supply(single) ft. ft in.
Industrial/Commercial OResidential Water Supply(shared)
rY8?GROUT. .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
-0 7Monitoring Recovery ft fL
Injection Well:
ft ft.
_!Aquifei Recharge QGroundwater Remediation
19.SAND/GRAVEL'PACK(if a 'liralile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
-:-)Experimental TechnologySubsidence Control ft ft.
BGeothermal
Geothermal(Closed Loop) Tracer 20.DRI=G.LOG(itti6-additidi'ilslieti.IfiieEes-s-":i '->''-(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock ty e in size,etc
^ d ft. ft I r
�' 1• ft ft
4.Date Well(s)Completed: _ Well ID# 0 O f
5a.Well Location:
-50 Awp-3 O���C ft ft _
C�i�� , ` J
Faciliaty/Ownler Name
� �/� J �1� Facility ID# ft ft
(if applicable)
a-,c
Pbysic Address,City,and Zip /�/' // ft. ft a t) 20
l ^ _ \L�6 U 93� ( 21:ItEMi1RKS' ;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(>�ell fie one IaUlong�s`r�icient) , � 22. 'lcation:
V\ N r W
6.Is(are)the well(s)Rtermanent 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 Wo with ISA NCAC 02C.0100 or I5A 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,only 1 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: (ft-) 24a. For All Wells: Submit this 'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@20Q'Qrdd22Q100) construction to the following:
10.Static water level below top of casing: {/I (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
�� A r• above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: W 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
LA f
air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: g
_�_�\ /� the address(es) above, also submit`one copy of this form within 30 days of
13b.Disinfection type: Wa� Amount: v completion of well construction to!the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Envirorrnrental Quality-Division of Water Resources Revised 2-22-2016