GW1-2021-07900_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Con tr c Infor
u .
14..WATER ZONES
FROM TO DESCRIPTION
Well ContractorNName ft fr.
?/(/r�/ ft ft.
NC Well Contractor Certification Number 15:OUTER.CASING:(for multi=rased wells)OR LIlVER ifa licible ".:.:
Morgan Well &Pump, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+1 ft ft 6 1/8/ in. sdr21 pvc
Company Name — 16;'INNER CA G OR TUBING' ebthermal 616'sed-loo '"- '
2.Well Construction Permit#:zk ✓ �20 FROM TO DIAMETER 1HIcxAlEss :• MATERLu,
List all applicable well construction permits(t.e.UIC,County,State,Vwlance,etc.)- ft- ft
3.Well Use(check well use): ft ft in.
17:SCREEN'.
...,.:..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMimicipal/Public ft ft in•
i Geothermal(Heating/Cooling Supply) JBResidential Water Supply(single) ft. ft in.
Ilndustrial/Commercial E3Residential Water Supply(shared) >iBr GROUT.
':."
'h-i ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft bentonite poured
Monitoring Recovery ft. ft.
Injection Well: ft ft
_I Aquifer Recharge Groundwater Remediation
� 19:SAND/GRAVEL"PACK Cif
a 'Iicitbl'
Aquifer Storage and Recovery [{3Salinity Barrier FROM TO MATERIAL Ei41PLACEMENT ME'rb:oD
Aquifer Test [3 Stormwater Drainage ft ft
Experimental Technology 0Subsidence Control ft ft
Geothermal(Closed Loop) OTracer 20.'DPJIJUNG.LOG'atticli`additidn'sl
FROM TO W10rhar1.1ne.1,S,11111r0CK1ype, in'size,etc)
EGeothermal(Heating/Cooling Return) .'Other(explain under#21 Remarks) ft. /� ft
4.Date Well(s)Complete20
d: Well TD# ft. ft
ft ftSa.Well Location: LePftWO ft
Fact tty/Owner Name Facility ID#(if applicable) ft ft
ft ft
so
ft ft n
cal Address, ity, Zip
3..
County Parcel Identification No.(PIN)
�J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 2Zon*
35.%oZ N -W.5 W
6.Is(are)the wells) Permanent or OTemporary
Sign oZitified.Well Contractor Date
By 'ringform,1 hereby certify that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: M'.Yes or ANNo with 15A NCAC 02C.0100 or 154 NCAC 02C.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#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 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 welts list all depths if different(example-3@.2200'aand 2@100D construction to the following:
7
10.Static water level below top of casing: %/%/ (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 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: 1 "`Y L� construction to the following:
(i.e.auger,rotary,cable,directpush,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&Infection Wells: In addition to sending the form to
the address(es) above, also submit Ione copy of this form within 30 days of
13b.Disinfection typ Amount: completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Enviroomental Quality-Division of Water Resources Revised 2-22-2016