GW1-2021-01967_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
^ Y 14.WATER ZONES
Well Contractor lName FROM TO DESCRIPTION
`Q ft. ft
\�N Y �cj\�9 ft. ft.
NC Well Contractor Certification Number QOetO 15.OUTER CASING for multi-cased wells O L]NER If i lteable
Morgan Well & Pump, Inc. 3�\orA S$c FROM To DIAMETER THICKNESS MATERIAL
+1 ft L ft. 61/8/ in. sd,21 Pvc
Company Name
16:INNER CASING OR TUB ING _eithermal closed ltio
2.Well Construction Permit#: FROMIf,
To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.)3.Well Use(check well use): ft in.
Water Supply Well: FROMCREEN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) t§Residential Water Supply(single) ft ft
Industrial/Commercial Residential Water Supply(shared) 1&GROUT_
Irri FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
at10II
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring !Recovery ft. ft.
Injection Well:
ft ft
Aquifer Recharge OGroundwater Remediation
19:SAND/GRAVEL-PACK Cif applicable)
Aquifer Storage and Recovery O Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft
_ Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer t 26.DRILLING LOG:ittach-addiddaal sheets if necessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION wlor,hardness,soiVrock type,grain size,etc
IL
` ft � '�
S zs-z `
4.Date Well(s)Completed: ` Well ID# ft �d ft. �f.+/l
Sa Well Location: rQ / ft 2 ft )
ft ft
—+Facility/Owner Name Facility ID#(if applicable) ft. ft
W!I70 S AA,ry n-h ,riv��J- h�C�fW►j' IL ft
Physical Address,City,and Zip fL ft
�s4.�rf SVV��iJ�JONv`�by �21�RRMARKC'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longpis sufficient) 22 ertificaq
N '� Gll).3��C86� W ��� Mir ZS zo
6.Is(are)the well(s)MPermanent or OTemporary Signa of i ed IDVeUl Co ctor Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or K)No with 15A NCAC 02C.0100 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 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-I 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: C. 5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: V (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
L above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �r% — construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)) l
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
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: S r4^✓1Cx r Amount: 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 Revised 2-22-2016