GW1-2021-07896_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD {GW-1 For Internal Use Only:
1.Well Cod tractor Information:
t14..WATER ZONES .
FROM TO DESCRU'TiON
Well Contractor Name �/ ft ft.
ft ft
NC Well Contractor Certification Number 15:OUTER-CASING:f&&ulfi=rased wells)Off£L7TIER if'a livabley-
Morgan Well &Pump, Inc. FROM I To I DLAMETER THICKNESS MATERIAL
+1 ft ft. 6 /8l in' sd21 pvc
Company Name /fU p,/ 16:'DUgER CASIN OR TUBING g eothermad clo'sbd-416d
2.Well Construction Permit#: S a�j FROM ft" TO DIAMETER THICKNESSI MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Ymriance,etc.)
ft, in.
ft ft in.
3.Well Use(check well use):
17:SCREEN,
Water Supply Well: FROM TO DIAMETER !SLOTSiZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft �•
:!)Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft ft in.
i Industria/Commercial DResidential Water Supply(shared) :18:GROUT-.
'Irrigation FROM TO ,MATERIAL -..EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft bentonite poured
Monitoring Recovery ft. ft
Injection Well: ft fr.
_.I Aquifer Recharge Groundwater Remediation •. .
19:SAND/GRAVEL-PACK if a•ildbib
Aquifer Storage and Recovery O Salinity Barrier FROM To FMATERIAL, CEMENT METHOD
Aquifer Test OStormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer :20.DPULING.LOG'(ittiiE-dditiori'sl slieetsifn"ecess
FROM TO DESCRIPTI N(color,hardness,soil rock ty J in'size,etc.)
Geothermal(Heating/Cooling Return) n
iOther(explain under#21 Remarks)
4.Date Well(s)Completed: �') Well ID# ft ft. Y'J O
Sa ft Well Location: /
fr. ft
acility/Owner Namel Facility ID#(if applicable) ft. ft c> 1
l
ft ft
Phys i ddress,City and Zip 1 .
O t�1 /P 1
County (� V`/ \ Parcel Identification No.(PIN)
V
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1'1 tY�
(if well field,ong laUlo is s nt) /1 � `�/► 22. ertification•
6.Is(are)the well(s) Permanent or OTemporary
Signature ertified Well Contractor Date f
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or JBNo with 15.9 NCAC 02C.0100 or 15A NCAC 01C.0100 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 ofthisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: /1 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 ifdijjerent(example-3Q200'an construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above cash:&,use"+•• 1617 Mail Service Cen i ter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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: Y L� 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
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection'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: kAJI W Amount: N oN, completion of well construction to the county health department of the county
where constructed.
Revised 2-22-2016
Form GW-I Nortb Carolina Department of Environmental Quality-Division of Water Resources