GW1-2021-01992_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Mntractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 3S Y O f^ CS ft ft
' I • ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR I INER if a liekble
Morgan Well&Pump, Inc. FROM To DIAMETER THICKNESS MATERIAL
Company Name
+1 ft '�3 ft 6116/ in' sd21 pvc
A ^ ���
`�( 16 INNER GASINGORTQBING` eottiermalclosed-loo :`
2.Well Construction Permit#:/�jd FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft d ft L in. S (Z6 t16
3.Well Use(check well use): ft ft in.
Water Supply Well: 17I'SCREEN: r..
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft ft in..
Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) ft ft in•
:hrdustrial/Commercial []Residential Water Supply(shared) 18.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft PO ft bentonite poured
Monitoring Recovery ft. ft-
Injection Well:
ft ft
_I Aquifer Recharge Groundwater Remediation
:19.-SAND/GRAVMPACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft fL
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer 16.DRIIJ ING.LOG attach'additional slieets if notes
FROM TO DESCRIPTION(color,hardness,soil/rock e, in size,etc)
Geothermal(Heatin .Cooling Return) Other(explain under#21 Remarks) ft Eb ft
r
4.Date Well(s)Completed: b �/r 2 Well ID# (�' tt b O ft. ro
5a.Well Location: d ft O ft
4�tn., f I Ia ft ft
Facility/Owner Name /�Facility ID#(if applicabl$) ft 2 ft s r
i/� R9 ✓tlaa.e3 I/I I �_ ft �/ ft
Physical Address,City,and Zip
yy
21 ft ft
c REMARKS:._.. -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: fa orllla
(ifwell field,one lat/long is sufficient) (� 22. r lcation:
N j �, D�,"JR Seciion
Za Z 1
6.Is(are)the well(s)EjPermanent or Temporary Si of Certi ell Contractor 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 EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Ifthis 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 1 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 e@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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. (/�i(�1 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6 Method of test: air pressure 24c.For Water Supply&Infection 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: Amount:�y Z 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