GW1-2021-07844_Well Construction - GW1_20211102

• I (�Y,�rint Form_-
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: k
I.,XVeU Contractor Information:
��, •14:WATER ZONES
FROM To DESCRIPTION
Well Contractor Name fL ft.
3S Y-A fL ft.
NC Well Contractor Certification Number
15:OUTER CASING,toc multi=cased wells OR L-IlyER if'a livable' :c'i
Morgan Well & Pump, Inc. FROM To DLIMETER THICKNESS MATERIAL
+1 fL fL 6 1/8/ in. sdr2l pvc
Company Name ((��IJ,•�1 w . r��'� O�,rr `I
\v I 16:'INNER CASING OR TIIBING eothei mal closed loo"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS •- MATERIAI.
List all applicable well construction permits(:.e.VIC,County,State,Ymiance,etc.) fL ft in.
3.Well Use(check well use): fL fL in.
.. ,
Water Supply Well: 17:SCREEN',::-FROM TO DIAMETER
I SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public fL ft in.
I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft
i Industrial/Commercial J Residential Water Supply(shared) 8 GROUT..
hri ation FROM TO MATERLAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o fL 20 ft, bentonite poured
Monitoring Recovery ft. ft.
Injection Well:
Aquifer Recharge Q Groundwater Remediation 19:SAND/GRAVEL-PACK if a hca bfe
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_i Aquifer Test [3Stormwater Drainage fL ft
i Experimental Technology Subsidence Control fL ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLDAG.LOG'(atti6`additidn'sl sheets,if neceis- '.:;:
I Geothermal(Heating/Cooling Return) _I Other(explain under#21 Remarks) FR M To a DES RIPT N(color,hardness,soiUrocktype,grain size,etc)
fL ft
4.Date Well(s)Completed: U`` t' Wel1ID# / ft. ft. ra
5a.a.'W,,ellltLocation- ft. ft
IL 7' Ske ,,rflt / o fL ft.
Facili//ty/O/�wn/er Name
/� ) Facility ID#(iiff� applicable)) fL ft-
�CJ171 D V rC/ ft. ft
Phys"alyAddress,City,and Zip ft. fL
� WAV
2
Sa I i.
County Parcel Identification No.(PIN) '-�'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if 11 fifield,one lat/long is sufficient)
N '! C�� C� �O W �CT'GII ( 7c1
6.Is(are)the well(s)0 Permanent or Temporary Signature of Certified Well Contractor Date `
By signing this form,I hereby certify iha the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: LJYes or MI No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well consu•uction 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: ;1� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200C'and 2Q100) construction to the following:
10.Static water level below top of casing: J (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: 6 1 (in.) 24b.For Iniection 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 LS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
,— / m C the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: e I'A2- Aount: V 0� completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 2-22-2016