GW1-2021-00773_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1 Contractor Information:
1
UVIS m5y:31M
14:.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 3' ft ft
J o�"�J ft ft
NC Well Contractor Certification Number 15;OUTER-CASING,(foi•multi-raced wells)OR LINER if a- licable
Morgan Well &Pump, Inc. FROM TO I DIAMETER THICKNESS MATERIAL
Company Name
+1 ft ft. . 61/B/ in' sd21 pvc
^ g /'1 /`�
S fV^e 1v, 16:INNER CASING OR TIIBIIVG -eothei=mal•do'sed-lod r
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'(xe.b7c,County,State,Variance,etc.)
ft fr. in.
3.Well Use(check well use): ft ft in.
-SREEN
Water Supply Well: M O_ DIAMETER ' SLOT SIZE TAiCKNESSt TA4ATERiAL
17.
Agricultural IMunicipaUPublic % ft I
!Geothermal(Heating/Cooling Supply) ej�,esidential Water Supply(single) ft. ft in•
—
i Industrial/Commercial oResidential Water Supply(shared)
�:18:GROUT. < .
i IITi ation FROM TO MATERIAL EMPLACEMENT METHOD&_AMOUNT
Non-Water Supply Well: 0 ft 20 ft' bentonite poured
Monitoring [)Recovery ft. ft
Injection Well:
ft ft
__I Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL'PACK if a"licatil'e
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_i Aquifer Test Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
BGeothermal
Geothermal(Closed Loop) Tracer eating/Cooling Return) -Other(explain under#21 Remarks) FROM To DES RIPTI N(color,Hardness,soil/rock type rain sip etc.)
Q ft. 11 D ft A r
4.Date Well(s)Completed:
5A.
IV_e4 Location:
0 ft ft
Facility/Owner Name r`YY�,�• Facility ID#(if applicable) ft ft. E
q0_% o"tl `V 1prii1/f (O �� ft ft
Physi l Address,City,and Zip
Tft. ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
-Tr
-�!log sufficient)N o -.>— W 22.C lion:
• SS
6.Is(are)the well(s)8Permanent or Temporary Signature of CeKif,,dell Contractor 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 WNo with 15.4 NCAC 02C.0100 or 15A NCAC 62C.0200 bell Construction Standai ds 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 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: �O (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1fdIerent(example-3Q200'and 2(a)100�
1 construction to the following:
10.Static water level below top of casing: V (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino 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 r L' construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Unl'derground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
f.
13a.'Yield(gpm) Method of test: air pressure 24c.For Water Suppiv&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 yr.n,, Amount oti 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