GW1-2021-07845_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1r,Wep Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft ft I
3S � �. _ ft ft
NC Well Contractor Certification Number 15;OUTER CASING(for multi-cased.wells)Olt-LINER if—i licible
Morgan Well & Pump, Inc. FROM I TO DIAMETER' I THICKNESS MATERIAL
+1 ft. ft- 61/8/ in. sd21 pvc
Company Name �AWV-6601� R IC INNER CASING OR TUBING'�eothermal clo'sed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.e.UIC,County,State,Variance,etc.) ft ft j in.
3.Well Use(check well use): ft ft in.
Water Supply Well: FROMRRF. TO DIAMETER. SLOT SIZE` THICKNESS FMATERIAL
-'Agricultural E)Municipal/Public ft ft in.,
Geothermal(Heating/Cooling Supply) KResidential Water Supply(single) ft ft in•
Industrial/Commercial DResidential Water Supply(shared)
A&GROUT,
?Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite i poured
Monitoring Recovery ft. ft.
Injection Well:
ft ft
_!Aquifer Recharge QGroundwater Remediation
19:SAND/GRAVEL PACK if ii 'livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL +EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRILLITiG.LOG(ittacti'idditionslsliiasifu'ecess" = . °:;::.`•::
1 Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM To DESCRIP ON color,hardness,soil/rock a rain size etc)
ft. ft
4.Date Well(s)Completed: Q�� Z 1 Well ID# ft. ezb ft.
Sa.Well Location: ft. ft.
Facility/Owner mmee M Facility ID#(if applicable)
W�•S � ` r� J�1'L 17G� ft ��.J ft 1
Physical AddFess,City,and Zip ft ft ! y n
21:REMARKS.,
County Parcel Identification No.(PIN)
t_;;}1i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
( ) e 22.C tification:
tf}yell d o e IaUlo su�f{ficient
1 N G( W
6.Is(are)the well(s)�Permanent or OTemporary Si ature of Certified Well Contract Date
Z
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an eidsting well: nYes or �No with 15A NCAC 02C.0100 or 15A NCAG0IC.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 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 GW-1 needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 4 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ll/�� (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a 00'and 2@100� construction to the following:
I
10.Static water level below top of casing: U (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
above, also submit one copy of this iform within 30 days of completion of well
12.Well construction method: ��r a� 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
(gp ) C air pressure 24c.For Water Supply&Iniectior Wells: In addition to sending the form to
13a.Yield m J Method of test: g
the address(es) above, also submit;one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the
e county health department of the county
where constructed.
j
P
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016