GW1-2021-00743_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' M ft i
ft ft
NC Well Contractor Certification Number 15:OUTER_CASING,(&o multiLdisea!wells OR LU!lER if'a'uciible'
Morgan Well &Pump, Inc. FROM To DIAMETER THICKNESS MATERIAL.
+1 ft ft 61/8/ in. sd21 pvc
Company Name �y�D
Lo LJ'i/A`+/ ` "`� 16:'INNER CASING OR TIIBI1�tG" eothei mal closed-loo r
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'(ie.U7C,County,State,Variance,etc.)- ft ft in.
ft in
3.Well Use(check well use): ft .
Water Supply 17:SCREEN',:•". . °:_:_. .`.:.<'._:,. .:;:.:.::' .: .:::;:-:.. .�..... ...
PP Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft ft th•
I Geothermal(Heating/Cooling Supply) Di Residential Water Supply(single) ft ft. in.
Industrial/Commercial LYResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPL9CEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring DRecovery ft. ft
Injection Well: ft. ft
JAquifer
uifer Recharge QGroundwater Remediation
•:19:SAND/GRAVEL-PACK if a'ii6bl'euifer Storage and Recovery SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Test [3Stormwater Drainage fLftperimental Technology Subsidence Control ft ftothermal(Closed Loop) Tracer :20.DRULING.LOG'(itticti`additioualslieets.ifueces-s"' ;FROM TO DESCRIP ION(color,hardness,soil/rock e,grain size,etc.othermal(Heating/Cooling Return) Other(explain under#21/Remarks) Oft ft
4.Date Well(s)Completed:'/17-21 Well lD# ✓ ft O ft r6`,
5 .Well Location: �j M V ft rtGwi
��r��— VL�r_Wa!e� ft ft
Facility/Owner Name /� Facility 1D#(ifapplicable) ft ft.
6?39 W AUC T17 Hwy Este— ft ft
ft ft
Physical Address,City,and Zip
L i q lG J/L U zr:1iEMARxs° -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifyAU field,one lat/long is sufficient) 22.Certification:
JS--Says N "- gI• y.SggZ w d(JU•i.�el
6.Is(are)the well(s)NoPermanent or Temporary
Signature of Certified ontractor 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: QXes or No with ISA NCAC 02C.0100 or 1SA NCACI02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform. 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 I 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: r (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 90 (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 this!form within 30 days of completion of well
12.Well construction method: r 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) �V Method of test: air pressure 24c.For Water Supply&Iniection 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: �` u Amount: 6 completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016