GW1-2021-00717_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W'ellll Contractor Information:f�A
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•14:.V4ATER ZONES-�". :.•I':..�:. :r":.,..':.'.'..._:.:.,
OM TO DESCRIPTION
Well Contractor Name ft ft
� S'la �
ft ft
NC Well Contractor Certification Number 15:OUTER.CASING,Ubr multf�asea wells Off£LIl R if a livable "..:
Morgan Well &Pump, Inc. FROM To DIAMETER THIclagms MATERIAL
+1 ft ft 61181 f in' sd21 pvc
Company Name I I S n Q q^ I INNER CASING OR T[JBING'g edthei oral dosed-loid
2.Well Construction Permit#: `17 O FROM To DIAMETER TTEUCxivESS MATERIAL•
in.
ft
List all applicable well construction permits'rz.e.IIIC,County,State,Variance,etc.)
ft. "
ft ft in.
3.Well Use(check well use):
17-SCREEN'.:,:. .:. _: ::.•i :::•::_ :,,.`.;..;.!.. :.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
!Agricultural rilMuaicipal/Public ft ft in.
_:]Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) ft ft
i Industrial/Commercial DResidential Water Supply(shared) LS:GRODT::
l lnl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft. bentonite poured
Monitoring Recovery ft. ft.
Injection Well: ft ft.
_I Aquifer RechargeGroundwater Remediation 19:SAND/GRAVEL"PACK tf a"]icalil'e
Aquifer Storage and Recovery Salinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology OSubsidence Control ft ft
N.
Geothermal(Closed Loop) Tracer :20.'DRILL�IG.I OG'(attacti`additiorial ibeet nece ne
FROM TO DESCRIP ION(w or,hardness,soil rock `type,grain •etc., <
Geothermal(Heating/Cooling Return) Other(explain under#21/Remarks) Q ft
4.Date Well(s)Completed: •�1 Well ID# p. ft ft v
ft , ft
5a.Well Location!
• i'�"�,�� /
Facility/ e�ame F`acilityID#(if applicable) ft ft {y
� .(5e— T44 1 r yo V /14- • ft ft
Physical Address, ,and Zip / ft ft
Ph
y Sp,s63f ir:ziEMARxs' -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in de.areas/minutes/seconds or decimal degrees:
(if ell field,one lat/long is sufficient) 22.Cer lion:
6.Is(are)the well(s) I'ermanent orI Temporary
Signatur of Certified Well Contractor e
By signing this form,I hereby certify that the wells)was(were)cofistructed in accordance
7.Is this a repair to an existing well: © ���III''''''Yes or o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
this is a repair,fill out known well construction information d explain the nature of the copy of this record has been provided to the well owner.
If
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: % V 1�16
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 ifdifferent(example-3 200'and 2@1001 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 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: O Y LI construction to the following:
(Le.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) -lob Method of test: air pressure 24c.For Water Supply&Infection Wells: In addition to sending the form to
/I/ the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type:�u��4N f Amount: completion of well construction to,the county health department of the county
where constructed.
Revised 2-22-2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources {