GW1-2021-00740_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1), For Internal Use Only:
1.Well Contractor Information:
14:.WATER ZONES
FROM. TO DESCRIPTION
Well Contractor Name ft ft
ft ft
NC Well Contractor Certification Number 15:OUTF:R.CASING,(&o multi-dried wells)OR LIIVER if a" lirahle)= :.:
Morgan Well &Pump, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+1 ft ft 61/8/ ` in' sd21 pvc
Company Name //�n ,_ ���� 16:INNER CASING OR TUBING"-eotheFinal closed loo r
2.Well Construction Permit#: I/'`J `/•�/ FROM TO !7�1ER THICKNESS MATERIAL.
List all applicable well construction permits'(ie.UIC,County,State,Ym•iance,etc.)-
ft.
ft. ft in.
ft in.
3.Well Use(check well use): 110 To" DIAMETER
Water Supply Well: SLOT SrZE TMCKNFSS MATERIAL
AgriculturalMunicipal/Public ft ft in, j
!Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft. ft in.
i Industrial/Commercial J Residential Water Supply(shared)
) 8iGROUT.': .:, _.. . •.. ..
!Irrigation FROM TO MATERIAL Y EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
_E Monitoring Recovery ft. ft.
Injection Well:
_!Aquifer Recharge __I Groundwater Remediation •. •;
•:19:SAND/GRAVEL'PACK if i 'llcabre
'Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRILUING.I;OG'(attadi`additional
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) ft U ft
4.Date Wells)Completed:(f — Zl Well ID# / �y. ft. Ll 5 ft r-
ft Ztfo ft LL
5a.Well Location: �7 f t. rAec-
Gn -:-.i�, l k.
V-44k r ol4ti,
Facility/Owner Name Facility ID#(if applicable) ft ft D E l,
ftft. fL
ft.
Physical Address,City,and Zip l g
Gf 17 Cca'A� � '21:RE1l4ARiSS :. ; • ; . ;:- : __::._;_:>::; . :.. . _ -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat11ong is sufficient) 22. er Ication
9!5--ssy8`{ N — Ft' Oc q?- W /IJb -r/ is?0 Zl
6.Is(are)the well(s)oPermanent or OTemporary
Sijtdture of Certified Well Contractor Date
By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or MNo with ISA NCAC 02C.0100 or 15A NCAC42C.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,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: �a (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereni(erample-3 a 00'and 2Q100� construction to the following:
10.Static water level below top of casing: 3a (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 Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of thislfoim within 30 days of completion of well
12.Well construction method: Y 0 construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY_VaLLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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 lone copy of this form within 30 days of
13b.Disinfection type: A�� Amount: �'?b Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016