GW1-2021-00770_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Wen Contr for Information:
14:.WATER ZONES
FROM TO DESCRIPTION
Well Con ctor N fL ft.
ft ft
NC Well Contractor Certification Number 15:OUTER CASING.(fdr multi-dried wells OR LIlYER if a livable'
Morgan Well&Pump, Inc. FROM ro DIAMETER THICILVESS MATERIAL
ft 6 1/a/ i in, sdr21 pvc
Company Name t�
16:'INNER CASING OR TUBING''eoffierrnal closed-1o6 :`
2.Well Construction Permit#: FROM TO DIAMETER TEIJ I ESS MATERrA.L
List all applicable well construction permits(r.e. c,Coun[vdState,Ya dance,etc.) ft ft in.
ft. ft in.
3.Well Use(check well use):
17:SCREEN'
:..:,
Water Supply Well: FROM TO DIAMETER SLOT SIZE TA[CKNESS NIATERiAL
Agricultural QMunicipal/Public ft ft in.
i Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft
i Industrial/Commercial E3Residential Water Supply(shared) 18:GROIIT:..:
Irrigation FROM TO I MATERIAL EMPL.A CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft bentonite poured
Monitoring []Recovery ft. ft.
Injection Well: ft ft
_1 Aquifer Recharge Groundwater Remediation lg.SAND/GRAVEL.PACK af a "usable
Aquifer Storage and Recovery Salinity Barrier- FROM I TO MATERIAL IMi uLACEMEPIT METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology [3Subsidence Control ft ft.
Geothermal(Closed Loop) E]Tracer :20:'DRILLING.LOG(attaeli'sdditidnAl'sliiets.ifriecess ...
FROM .TO DESC IPTI N(color,hardness,soil/rock type, in'size,etc.)
Geothermal(Heating/Cooling Retum). _iOther(explain under#21 Remarks) ft ft.
4.Date Well(s)Completed: Well ID# ft. fL ho
G1Y
5a.Well Location: ft. ft
d "
Facility/Owner Name Facility lD#(if applicable) ft fr
0 <7ft. ft 21
ft ft
"ISFal Address,City,and Zip
0 1I.REMARKS—
County Parcel Identification No.(PIN) of o,-C'd:tt li iPw :Fi rr.e j(I�l(y�ll it
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUllong is sufficient) II 22. tification:
N yDa �1 � W k4PA
6.Is(are)the well(s)JOPermanent or [3Temporary V1h
Certified Well Contractor Date
his form,1 hereby certify that!the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or NNo 5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Ssandmds and that a
If this is a repair•,frll 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 Geo robe/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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exmnple-3 c@200'and 2@100) construction to the following:
10.Static water level below top of casing: 3 (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 Ini.ection 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 0"'r 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 Supply&Injection Wells: In addition to sending the form to
f' `N the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection typ -u -- Amount: Gib• �� completion of well construction to the county health department of the county
where constructed.
E
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016