GW1-2021-01968_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. ll Contractor TrAformation: //A�
AV t 14.WATER ZONES
Well Contractor Name �°! FROM TO DESCRIPTION
�r SV. fL ft
ft. ft
4
NC Well Contractor Certification Number ,`N r\�
\U \rg V 15:OUTER CASING for multi-eased wells 'O$LINER.if a" llcable 1 `..
Morgan Well&Pump, Inc. ! O�Qrys FROM TO DIAMETER THICKNESS MATERIAL
�$ +t ft I ft 61/8/ In' sdY11 pvc
Company Name (�;
` 16.INNER GASIN OR TUBING "eothei=mal closed-loo
t
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft in.
I Well: 17.SCREEN
Water Supply Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft ft in.
:3 Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft in•
Industrial/Commercial Residential Water Supply(shared)
18.GROUT.
ITrt ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft 20 ft• bentonite poured
Monitoring ORecovery fL fL
Injection Well: ft. ft
_Aquifer Recharge Groundwater Remediation
.19.-SAND/GRAVEL PACK if ii licable
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 126.DRILLING LOG attach addiddnal stieets if necessary)
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc
r� 0 ft � ft r 4
4.Date Well(s)Completed: L� ` Well ED# ft it. ,0 f�'4 r '4-
5a.Well Location: 0 ft �/ ft k
fL 70 n 7r i
Facility/Owner Name' / ut Facility ID#(ifapplicable) v ft ft /�
LI I Iq v a I�;/1 &Vt oet(I/"'e ft. ft. - —
Physical Address,City,and
Zip ft. ft _
21.'RFAARKR
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(iffwwel�l field,one Iatt loong is sufficient) /y 22.Ce i a ion r� 1
N --��. `( " W
6.Is(are)the well(s) Permanent or OTemporary Signature o Certified W Co ctor Date
By signing this form,I hereby certify that the we s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Ji 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 Lind 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 details. You may also attach additional pages if necessary.
construction,only I GWLs needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2�d A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d8erent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: Vooy (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
n 1 above, also submit one copy of this form within 30 days of completion of well
(i.Well construction method K,UT(A�� construction to the following:
e.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) 10rv, 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 type:. JI 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