GW1-2022-01723_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i
l�e6entractor ti n: '
J`a 14:.WATER ZONES
_ . .. .:­.——7-
FROM TO DESCRIPTION .
WellC � I/�\ ft ft.
ft it.
NC Well Contractor Certification Number 15.OIITER CASING,(for multi rased*ills)QR L1NER if'a" licable
Morgan Well &Pump, Inc. FROM T DIAMETER THICKNESS MATERIAL
sd21 pvc
Company Name � ��
16:INNER CASING OR.TUBING'�eothermal*clo'sed-hod'
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'(1.e.WC,County,State,Valiance,etc.) ff' fL in.
3.Well Use(check well use): ft ft m
Water Supply Well: 17.SCREEN•.:,:. .:<. i_: :,;'':.::• ?.. .
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_•:Agricultural QMunicipal/Public ft ft
I Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) g, ft. in.
I lndustrial/Commercial i Residential Water Supply(shared) =•..:r=
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring Recovery ft ft.
Injection Well: ft ft.
-,)Aquifer Recharge n-J Groundwater Remediation
19:SAND/GRAVEL'P SCK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMLACEMENT METHOD
i Aquifer Test E)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft.
J Geothermal(Closed Loop) Tracer :ZO.DRIhLING.LOG'(attadi=addiflJri'sl sheets if iiecessa"'::; : is
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft i
4.Date Well(s)Completed: Well ID# b ft ft G
5a.Well Loca' ft Omit
Facility/Owner Name Facility ID#('.applicable) N ft ft.
Pb)�ical ddtess,City,and Zip �C�12 ft.. ft
y-/�1: ro S V
21:I2E114ARKS•-
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22 rtifieation:
'
�q [4 _N W
6.Is(are)the well(s) Permanent or Temporary Id,
tore Certified Well Contractor Date
n [his form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or�No S CAC 02C.0700 or 15A NCAC 02C.0200 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 this forth. 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: -21M (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 t@200'and 2Qa 100) 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 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: construction to the following:
(Le.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&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 t7 Amount: Utz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016