GW1-2021-00780_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. ell Contractor Inf ma'on:
14:WATER ZONES
FROM TO DESCRIPTION `
Well Con et r Name ^
'/r]J• ft ft
3�a� ft ft.
I
NC Well Contractor Certification Number
15;OUTER.CASING,U&multi-dosed wells)OR 13VER if"a"
Morgan Well &Pump, Inc. FROM I TO DIAMETER ' THICMNFSS MATERIAL
+1 ft (fj0 ft 61/8/ [In' sd21 pvc
Company Name
35U�6�� 16'INNER CASING OR TQBING ebthermaI elo'sed-loo'
2.Well Construction Per #: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in
3.Well Use(check well use): ft in
17:SCREEN'.: . .
Water Supply Well: FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft ft in. 1.
:_]Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
i lndustrial/Commercial AResidential Water Supply(shared)
::18r GROUT-.''.
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring DRecovery ft. ft.
Injection Well: ft ft.
_I Aquifer Recharge ])Groundwater Remediation
- -19:SAND/GRAVEL-PACK af a 'licatil8 _ ,• .. - •: ' ` -
Aquifer Storage and RecoverySalinity 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'(attacti'sdditiorisl'slieetsif iiHeis" -''= €
Geothermal(Heating/Cooling Return) -Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock ty a rain'size etc.)
0 ft. D ft '
4.Date Well(s)Completed: l Well ID# ft R•
5a.Well Location: ft r �
f+=
Facility/Owner Name Facility ID#(if applicable)
e-
ft.
ft. ft
P sisal Address,City, Zip ft ft r i :.s — h H
_• `^ `_ . 21?-RF.MARKR'-..'�:'.:..'• .; . .... ,.. ....�`r�" _ -
County Parcel Identification No.(PIN) OF I' 8 2021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4;,t,
(if well field,one lattlona is sufficient) Q/'� [ 22.Certification:
.570 N V�/ � T� W
6.Is(are)the well(s)J1 Permanent or OTemporary S;ena e o e ied Weellf Contrraactor Date
By enin . form,I hereby ce716 that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: rJ!Yes or JpNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standm•ds 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#11 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 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: � (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(a)100D construction to the following:
10.Static water level below top of casing: a (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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: O Y LI construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
i
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&Iniection!Wells: In addition to sending the form to
l the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: `w N Amount: ga completion of well construction to the county health department of the county
where constructed.
Form GW-I Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
E