GW1-2021-00775_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1). For Internal Use Only: j
1.W ntractor Info, on
I
14.WATER ZONES
FROM TO DESCRIPTION `
Well ontracto Name ft• ft.
ft ft. E
NC Well Contractor Certification Number 15:OUTER CASING,(fric multi-dried wells 0I2 LIlVER(if'a" licable'-s'1'".:.:
Morgan Well &Pump, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft. 61/8/ ( in. sd121 pvc
Company Name A 16;' R CASING OR TUBING eo'thermal clo's8d lod
M
/�!1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft
List all applicable well construction permits(i.e.UIC,Comtty,State,Variance,etc.)- R• in.
ft. ft in.
3.Well Use(check well use):
17:SCREEN.
Water Supply Well: FROM TO 'DIAMETER SLOT SIZE THICKNESS MATERIAL
_'Agricultural lMunicipabTublic ft. ft
i Geothermal(Heating/Cooling Supply) IffiResidential Water Supply(single) ft. ft
I Industrial/Commercial ,Residential Water Supply(shared) ,r18rGROUT:
S h1i atlOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. pp ft bentonite poured
Monitoring Recovery ft. ft.
Injection Well: ft ft.
__I Aquifer Recharge r_I Groundwater Remediation 19:SAND/GRAVEL PACK if a hcab l'e
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test E3Stormwater Drainage ft ft.
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRILLIlVG.I OG'(attae]i additidnal sli'eets if iiecess'")':;' `=
FROM TO DESCRIPTION(color,hardness,sowrock type, in'size,etc.)
Geothermal(Heating/Coolingl Re m) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: l Well ID# ft. ft
J'g ft ft _
54 ell Lo ti n:
Q . :c
1 1
Facility/Owner am e Facility ID#(if applicable) t O�
ft ft
Fjqsical Address,City,and Zip ft ft at 7 r t i j` �j"jl
a 'RFMARKR"' • `
'County Parcel rdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well 1 field,on �ng is sufficient)N _ `�� 22aCcation:
s
:�1 W
6.Is(are)the well(s)J§Permanent or OTemporary
Signs e f C •fied Well Contractor Date
By siening th' rm,I herebv certify that;the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or RNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: % 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(example-��3Q200'and 2@100D construction to the following:
10.Static water level below top of casing: `"�� (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
ll.Borehole:diameter: 6 (in.) 24b.For Iniection 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: O Y LI construction to the following:
(i.e.auger,rotary,cable,directpush,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
b the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:L� ar�H Amount: completion of well construction to the county health department of the county
where constructed. f
Revised 2-22-2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources