GW1-2021-00777_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I
14.WATER ZONES
FROM TO DESCRIPTION'
Well Coatracto Name
�� ft fr.
3�1 ft ft. �
NC Well Contractor Certification Number
15:OIITER.CASING.(fair taulti=cased wells OR LIlYER(if'a'" livable',�
Morgan Well &Pump, Inc. FROM To DIAMETER TirlclovEss MAtRurnr.
+1 ft. ft. 61/8/ in. sd21 pvc
Company Name
16:IlVNER CASDqG OR TIIBING eot)iei�mal closed-lob'
2.Well Construction Permit#: FROM TO DIAIvD TERI THICKNESS MATERILAL
List all applicable well construction permits rz.e.EUC,County,State,Variance,etc.) fr ft in.
3.Well Use(check well use): ft ft. inn.
I .-SCREEN--'.
:.,:.:,.e.:_r.. . ..... ...
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
•.Agricultural C]Municipal/Public ft ft �•
i Geothermal(Heating/Cooling Supply) if Residential Water Supply(single) ft ft in.
Industrial/Commercial DResidential Water Supply(shared) 18:GROUT.'
i 11-r1 ation FROM TO MATERIAL'' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fr- bentonite poured
Monitoring Recovery ft. ft.
Injection Well: ft ft
!Aquifer Recharge []Groundwater Remediation
19:SAND/GRAVEL'PACK if a'liralii'e `•
'Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRILLING.LOG'(atticti`additidn'al sli'eed.if iiiE ss•"':':;
FROM TO DESCRIPT ON(color,hardness,soil/rock type, in'size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft a ft
4.Date Well(s)Completed: Well ID# 1 b ft.
5a.Well Location: a-s ft sO ft
ft ft
SO
Facility/Owner Name Facility ID#A(if applicable) u it. tzmft
C.
ft. .��•\f �, ' F r
Ph at Address,City,and Zip ft b ( f
.`216'RRMARKR",.�d":
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C cation:
�/7,
6.Is(are)the well(s)oPermanent or C3Temporary Sijh
e o rtifie ell ontractor Date
fininA
orm,I hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well' QYes or fNo ISA 02C.0100 or 15A NCAC 02C.0200 Well Consnnction 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 wprovide additional well site details or well
construction,only 1 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: A .J (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: O (ft.) Division of Water Resources,Information Processing Unit,
If water 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 0 1 "t 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 Cen tr Raleigh,NC 27699-1636
13a.Yield(gpm) GiJ 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 typ : Amount: p QZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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