GW1-2021-00738_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Infor ation: I
S
•14:.WATER ZONES
FROM TO DESCR1PTiON
Well Contractor Name V ft
l a A ft ft
NC Well Contractor Certification Number 15;OUTER.CASING,(for multi=cased wells O t LINER(if a 'licahle
Morgan Well &Pump, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
+1 ft O ft I 6 I.81 in' sd,21 pvc
��1 u 1 /` /�il 16:INNER CASING OR TQBIVG eot tiermal closed-lob'
2.Well Construction Permit#: `�r/hj'L/` (J"� (/ FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permiu'(i.e.UIC,Comity,State,Variance,etc) ft ft. in.
ft ft in.
3.Well Use(check well use):
1 Well: 17:
WaterSuSCREEN'..:=.;<. '::, :..::::.:... 'F.;.. .:: • `
Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft ft in.
I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
I Industrial/Commercial DResidential Water Supply(shared) ;18:GROUT: `:.'.':
hri ation FROM TOMATERIAL EMPL.4CEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring []Recovery ft. ft
Injection Well: ft ft.
I Aquifer Recharge []Groundwater Remediation - 77
19.SAND/GRAVEL•PACK if a'licilil'e
777777
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft
Experimental Technology []Subsidence Control ft ft.
Geothermal(Closed Loop) []Tracer 20.DRMEING.LOG'(itticli'additidiiM sheets.if necess"'j
FROM TO IDESITT ON(wloq hardness,soil/rock type, in size,etaGeothermal(Heating/CoolingRettum) J Other(explain under#21 Remarks) ft / ft4.Date Wells)Completed: 1 Well ID# ft b O ft' �J/�- a'
5a.Well Location: vft (G ft ���� f
'/ ft Q ft s
rub y �ii�lso�- o � � , __���-L_ ...
Facility/O ner Name / Facility ID#(if applicable) Oft G ft' ��� ��r/�•' ��z
y/)/ ' / �N % ft.
/„,City, •- / ft ft
Physical Address, d Zip /���� _ •_ _
li�n Co
County Parcel Identification No.(PIN)
5b.Latitude and longitude in decrees/minutes/seconds or decimal degrees:
(if 15d,one latllong is sufficient) p 22. ratio .
C16 N 8l, W /uarrcrn�e 2,F Zo 1
6.Is(are)the well(s)RPermanent or []Temporary
Signature of Certified Well Contrac Date
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 Pallo with 15.4 NCAC 02C.0100 or I5A 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 thus 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: yZO (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 22@100) construction to the following:
10.Static water level below top of casing: �°' (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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: 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
i
13a.Yield(gpm) Z-5,-- 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: v Amount: rou completion of well construction to the county health department of the county
where constructed.
k
i
Revised 2-22-2016
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i