GW1-2021-01998_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
e I Contractor Name -1 6f,
NC Well Contractor Certification Number v �r�$1hg 15.OITTER CASING Lor multi-cased wells OR LINER if a livable
Morgan Well& Pump, Inc. 3tito�pr e ;o� FROM I TO DIAMETER THICKNESS MATERIAL
+1 ft ft 61/6l in' sdf11 pvc
Company Name _r ,\� !
U (J 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM I To DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft it. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ElMunicipal/Public ft. ft
in.
Geothermal(Heating/Cooling Supply) &esidential Water Supply(single) in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft. bentonite poured
Monitoring :Recovery ft. fL
Injection Well: ft ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEI.PACK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM I To I MATERIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attaeb additional sheets if necessary)
rFROMTO DESCRIPTION(color,hardness,soil/rock e, rain siu,etc.
Geothermal(Heating/CoolingReturn) _ Other(explain under#21 Remaz U ft4.Date Well(s)Completed: ' �2� Well ID# 3 a ftD5gg. ell Locatiq� Oft �✓L 5��n�
�acility/Owner Name J l Fa tityID#(ifapplicable) Ejb ft �ft"
si LG J �� - ����1-o,, ft ft
Physt 1 Address,CiLz
d Zip ft fL
Cf At() 21.REMARKS
County V Par&I Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if�well�field /one1� n� sufficient) ^ S.1 1 Z 7 O 22.Ce cation:
N —oy WS�zo'Z
6.Is(are)the well(s)r)Permanent or ElTemporary
Signature of Certified Well Con 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: [3 Yes or [3No with I5A NCAC 02C.0100 or ISA 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-l!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: O O (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 00' id
@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 casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (fin.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/I/Q L above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: � 1 '1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY LLS 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 type: A v "`s 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