GW1-2021-07915_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Co tractor Information:
14..WATER ZONES
WellContracorName FROM ft TO ft DESCRIPTION
'Vi
ft ft.
NC Well Contractor Certification Number f
;�;''" �.��;,`;•;�_' 15:OIIT'ER_CASING:focmniti=cased wills)O R-LS1yER(if"a licable'�
Morgan Well &Pump, Inc. FROM TO `,DIAMETER THICMWS5 I MATFRM
+1 ft ft. 61181 iin' sd21 pvc
Company Name
ol3bOb 2OZ1 ROMER N CASING OR TIIBING eotherutal closed loo
2.Well Construction Permit#: - FROM TO DIAMETER THICKNESS MATERIAL
, MATERIAL
List all applicable well construction permits i.e.WC,CawtN,State,Ya innce,etc.) ft ft in.
3.Well Use(check well use): ft ft. in.
17.SCREEN'.:-.
Water Supply Well: FROM TO I DIAMETER I SLOT STZE I TMCK7VESS �MATERTAL
Agricultural jMunicipaMblic ft ft �•
i Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft ft in.
I hrdustrial/Commercial Residential Water Supply(shared) 18:GRODT
'Irrigation FROM TO .• IAL MATER y. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. zo ft bentonite poured
Monitoring DRecovery ft ft.
Injection Well: M ft
_I Aquifer Recharge Q Groundwater Remediation
19:SAND/GRAVEL-PACK Cif a'livable .'.
'Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL MEN OD
METHOD
Aquifer Test [3 Stormwater Drainage ft ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILL�G.T OG'(attacli-additional sLeetsif iiecess `i`''
FROM To
1 Geothermal(Heating/Cooliag Return) —) I Other(explain under#21 Remarks) DESCRIPTION(co r,hardness soiUrock typin's ze etc.
h � ft Zd ft
4.Date Well(s)Completed: 6+ � 2 1 Well ID# C-ft ft
ft ft f
5a.Well Location: 1`
5DW�b r-�) \ Gsr+�t/t J-L L � f /�6-11ft t
Facility/Owner
r Na�mee.� ,,r Facility ID#(if applicable) 1 OZ&ft 2 70 ft- 6
t'" 4 \ ` 1 �� �r- �L(E! 1 fA 'J •6��f ft. ft
Phy"cal d ess,City,and Zip ti4� ft ft
Co ty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one]aUlong is sufficient) �J z
cation:
3� . o� Zz N . AS W D
6.Is(are)the well(s)JIPermanent or OTemporary §196reeCertified Well Contractor Date
By signing this form,1 hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or JVNo with 15A NCAC 01C.0100 or 15A 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 io the well owner.
repair under#21 remarks section or on the back ofthisform. 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: % SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l.106
� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii Brent(example-3Q200'and 2Q100� construction to the following:4
10.Static water level below top of casing: y (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casinng,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'form within 30 days of completion of well
12.Well construction method: r 1 "`Y LI construction to the following:
(Le.auger,rotary,cable,direetpush,etc.) _ a
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
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