GW1-2021-00730_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Info rna on:
-14:WATFR ZONES r.. .:
FROM TO DESCRIPTION
Well Contrac r Name fL ft.
ft ft
NC Well Contractor Certification Number 15;OUTER CASINGHfd
(fo�rnulfl=rased wells)Oft L1NER if a- liciible
Morgan Well &Pump, Inc. FROM TODIAMETER: THICKNESS MATERIAL.
+1 ft. 61/8/ in' sd21 pvc
Company Name �� '�� 16:IIVNER CASING OR TIIT�eatl2.Well Construction Permit#: a7 FROM TO THICKNESS MATERIAL
List all applicable well constructionpermits ri�C County,State,Variance,etc.)- ft ft.
ft. ft in.
3.Well Use(check well use):
17:SCREEN._,:. .;. W. .Water Supply Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipaOublic ft ft
I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft �•
I Industrial/Commercial DResidential Water Supply(shared) `I&GROUT.'',
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft• bentonite poured
i Monitoring QRecovery ft. ft.
Injection Well: ft. ft
]Aquifer Recharge OGroundwater Remediation -. .
19.SAND/GRAVEL'PACK if a'licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAI. EMPLACEMENT METHOD
i Aquifer Test Stormwater Drainage ft ft
!Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer :20.'DRTLLaiG.LOG'(atticli'sdditidri'sl slieets.if necess-")':'i:
FROM TO DESCRIPTIO (col ,hardness,soiUrock type,grain'size,etc.
I Geothermal(Heating/Cooling Return)
r Other(explain under#21 Remarks) ft ft
4.Date Well(s)Completed:j�[_j 1 G 1 _ Well ID# �Js ft 450 ft
+5 .Well Location: JYC5 ft 405 ft
n 5 ft
Facility/O Name ,�,��nn,,//pp��,�� mMFacilityID,#(ifapplliiccfable) ft. gz0ft. _
240 t6we y� 1' �Orem ft
ft ft
Physic.Address,City,and Zip
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lonng is sufficient) .Q 22.Certification:
35 .S IT G N . O 3f�3 W S
6.Is(are)the well(s)MIPermanent or [3Temporary
�,tlr,
aue C iied Well Contractor Date
' orm,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [!Yes or SNo 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 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: Zo (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths irdiffierent(example-3@2200'and 2(a3100D construction to the following:
10.Static water level below top of casing: J O (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 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: 00Ir LI 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 SupnlV&Iniectionl 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:�bZ completion of well construction to the county health department of the county
where constructed. I
I
f
Revised 2-22-2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
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