GW1-2021-07891_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well tractor
nfol• n i
14..WATER ZONES :
FROM TO DESCRIPTION c
Weli Contractor e ft ft
v ,
ft ft
i
NC Well Contractor Certification Number 15:OUTER.CASING,foie&ulti-cased wells OR LIPIER if a licable: .:
Morgan Well &Pump, Inc. FROM TO DIAMETER I MATERrAL
+1 ft IIJ99 ft. 1 61/6/ in' sd121 pvc
Company Name 2 I INNER CASING OILTUBING -e6ther&s1 clo'sed-lod' : -
FROM TO
2.Well Construction Permit#: 7� DTAMRTER THICKNESS MATERIAL
fL in.
List all applicable well construction permits i.e.tuC C01121% tale,Variance,etc.)- ft
ft ft in.
3.Well Use(check well use):
Water Supply Well: FROM TO DrAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft fL in.
i Geothermal(Heating/Cooling Supply) OWesidential Water Supply(single) ft ft in.
GROUT
I Industrial/Commercial Residential Water Supply(shared) ,..- ,..; ...:.- ` .'•-
18: :
'hTi ation FROM TO 'MATERIAL ... EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft bentonite ! poured
'.Monitoring DRecovery ft ft.
Injection Well: ft ft.
_-I Aquifer Recharge —i Groundwater Remediation
'19:SAND/GRAVEL"PACK Cif a licalile
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage M ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) [3Tracer 20.DRMECNG.LOG'(ittidi'addition'a1 sheets if
FROM TO DESCRI TIO color, ardness,sots/rock typ air];ize,etc.)
i Geothermal(Heating/Cooling Return) -Other(explain under#21 Remarks) ft -:P ft
4.Date Well(s)Completed: D Well DV � ft fi 1
V ft 4845 ft bolKo
ff
Well Lo do
Sft Ob ft
Facility/Owner Name Facili M#(if applicable) wI O fL
r.�
y/ I ft. ft. at v
ft
Pal Address,City,an Zip _Laty Parcel Identification No.(PIN) :e
,f:.;,•:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
/wl
Signa rtifi Well Contractor Date
6.Is(are)the wells)&Permanent or [I Temporary
By signing this f r ,1 hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or �No with IAA NCAC 01C.0100 or 15A NCAC.02C.0200 WeR Construction Standwd;and that a
Ifthis is a repair,fill out known well construction information and explain Are 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 Geo robe/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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
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 if different(example-33@200'and 2 aC3100� construction to the following:
10.Static water level below top of casing: J� (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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 O"Y LI construction to the following:
(Le.auger,rotary,cable,direct push,etc.) j
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
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 county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016