GW1-2021-00741_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
IfTill
lCContractor Information:
14:.WATER ZONES
ROM TO DESCRUPTION c
W C tractor ame ft ft !
ft ft.
NC Well Contractor Certification Number
15:OIITER_CASING:(foc multi=rased
Morgan Well &Pump, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+t sd21 pvc
Company Name ICINNER`7)w /{ CAS
(t� Uv I �{1 ING R TIIBIIVG' eotliecmal dosed rod'
2.Well Construction Permit#. U FROM I TO DIAMETER THICKNESS - MATERIAL
List all applicable well construction permits'(ie.U1C,County,State,Parlance,etc.) ft ft. in.
m
3.Well Use(check well use): ft ft
1 17:SCREEN'.:,:.
Water Su <.:_.:. _... :::.:.:;:r:::•: :: -."..:..;,`: i{.. ;,:. ..:'• ` =:
PP Y Well: FROM TO DIAMETER SLOT SrZE THICKNESS t\fATERiAL
Agricultural Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) F&Residential Water Supply(single) ft. ft
::
i Industrial/Commercial Residential Water Supply(shared)
18:GROUT:
hai ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. bentonite poured
Monitoring DRecovely ft ft
Injection Well: ft ft.7_-I Aquifer Recharge L_'1 Groundwater Remediation
19:SAND/GRAVEL PACK d a 'licible
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) [ITracer 20.DRILLING.LOG'(itti6-additionals7ieetsifiiecess
FROM TO DESCRIPTION(Col ,hardness,sowrock e,grain size,etc.)
J Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft 0 ft v
4.Date Well(s)Completed: Well ID#
5a.W ll Location:
ft ft
Facility/owner ame Facility ID#(if applicable) ft ft
ft ft ,
Physical ddress,City,and Zip ft ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field/ori,lat/long is sufficient) n a 2 Certification:
>5G! /�9�i N —b��2DIs� W
6.Is(are)the well(s) Permanent or QlTemporary
Signature of Certified Well Contract r Dat
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: nYes or JaVo with 1SA NCAC 02C.0100 or ISA 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 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: OZU V (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@100D construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,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 thism'for within 30 days of completion of well
12.Well.construction method: 0 Y L� 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 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: r"nJCL" Amount: PUZ 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