GW1-2021-01996_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�Ww-7o�l-t--a�--'� -F:WATER-ZONES
WD3LCohtractor Name FROM TO DESC T10N
NC Well Contractor Certification Number 15.OUTER CASING:for i ultl4tased.welts OH I IPfEER if a Hcable),
Morgan Well& Pump, Inc. FROM To DIAMETER THICKNESS MATERIAL
+1 ft ft 6116/ in. sd21 pvc
Company Name / f) �� r ,,\/^l( ►l'/7V/ 1I v U 16�I -INNER CASING OR TiJBING``eoth�ei�mal.`closed-lod` `
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(r.e.UIC,Coutu,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17;SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipaUPublic ft. ft in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft in,
Industrial/Commercial Residential Water Supply(shared)
18.GROUT '
In'i ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring DRecovery ft. ft
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
19;SAND/GRAVEL`PACK(if applicable)
_Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology 13 Subsidence Control ft ft.
Geothermal(Closed Loop) 13 Tracer 26.DRII.LINGLOG:attach-additioual sheets if nicessa' _
FROM TO DESCRIPTI color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/.CoolingReturn) Other(explain under#21 Remarks) d ft ft. '-
o
4.Date Well(s)Completed: ,[y�8 r1\ Well ID#� ft J ft. V/` '�, f-r!D
5a.Well Location: (� ft o ft. SO-V k+���
Facility/Owner Name L Facility ID#(if applicable) ft ft.
3 1 V O A'sJ_re /�4'.JAL' 41 ft f
Physical Address,City,and Zip r-/� ft ft
2LRF.MARKR
County Parcel Identification No.(PIN)
rl;,lrnDa
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^'
(if well field,one lavlong is sufficient) 22. rtification:
3 q*I To N g 1 i 7 Z663 W dune $
6.Is(are)the well(s)a Permanent or OTemporary SVatore of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJYes or oNo 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:_ 2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r100 M-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'mud 2 100D 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 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: �4T S/
construction to the following:
(i.e.auger,'i o[ary,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&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: 1 Jtr Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016