GW1-2021-07839_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We] Contr A;formatin: I
04.iWATER,Z0NES` .' z F.r •'
FROM TO DESCRIPTION
Well C ntractor me
y°
± ft. ft.
NC Well Contractor Certification Number 15:OUTER'CASING.(fdr.' lh cased,`w°ells'ORT INER'(if`a hca6le _' Y
Morgan Well & Pump, I N C FROM DIAMETER THICKNESS MATERIAL
1 ft ft. 61/8 rn sdr21 PVC
Company Name 1`6:'INNER�CASING.OR.TUBING(""eother'mal closed log
2.Well Construction Permit#: 0_ FROM TO DLAMETER THICKNESS i�L4TERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. ft in.
ft in.
3.Well Use(check well use): ft,
Water Supply Well:
pp y FROM TO DL4 ETER SLOT SIZE ~THICKNESS �•MATERL4L
❑Agricultural ❑Municipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIALw EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- bentonite poured
❑Monitoring ❑Recovery
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater•Remediation
�19�SANDYGRAVEL PACK rf a"'licatil'e +
❑Aquifer Storage and Recovery ❑Salinity Barrier, FROM TO MATERL4L EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) []Tracer 20 DRILLINGISQG,attabh"!ddittoual"shee"ts;ifnecessa
FROM TO DESCRIPTI N color,hardness soillrock e,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft.
4.Date Well(s)Completed: Well ID# "S ft. fL
5a.Well Location: ft. ft.
i ft. ft. ,A-
r
acili�tv w7�ner Name Facility ID#(if applicable) ft. 07l ft h In
/// AI ft. ft.
laical dress,cCity,and Zip rr j ft ft
�� `\ �1GAC � •21 BEMARxs _...�u<:; y ..: � _�IZi�.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellreld one Iat/llo�ng is sufficient) f� �., 22.Cer lion:
t 4JL— N-10, W ,'
M24
6.Is(are)the well(s): LRE;'ermanent or ❑Temporary Signgj';� d Well Contractor Date
By si I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A 00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this forme.
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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER=of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 00'and 2Q100�
24a. For All Wells: Original form to Division of Water Resources (D)AIR),Static water level below top of casing: 1 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
11.Borehole diameter: 6 (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
o Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rota'y
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
t
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
a i r pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
e
s
13b.Disinfection type '1 Amount: ac_
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018