GW1-2021-02017_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.WtContr,%ctor for ation:
�5
14.,WATER ZONES ,
ll FROM TO DESC
We ntractorName RIPTION
1'/�Jl/1 ` tl ft. ft.
11 J �1 elo N ft. ft
NC Well Contractor Certification Number p(oS' iXo� 15.OUTER CASING for multi-cased.wells OR LINER(if a livable c
Morgan Well & Pump, Inc. � �r¢5ec FROM To DIAMETER THICKNESS MA'raarwr.
. ,Company Name +t ft. ft. 61/81 ln. sd21 pvc
��"
VX 16:INNER CASING OR T[JBING `eothermal closed-lod '
2.Well Construction Permit#: FROM To DIAMETER THICKNESS jyIATFRTAr
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) fL ft in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17 SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) timesidential Water Supply(single) fL ft. 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 ORecovery ft ft.
Injection Well: ft. ft.
Aquifer Recharge []Groundwater Remediation
.19.SAND/GRAVEL-PACK if a livable
Aquifer Storage and Recovery C)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. If.
_ Experimental Technology Subsidence Control fa M
Geothermal(Closed Loop) QTracer =20.DRILLING.LOG:attaeli'additional sbeeta if necess
Geothermal(Heating/Cooling Return) _ -Other(explain under#21 Remarks) FROM I TO DESCRIPT ON(color,hardness,sail/ ck type,grain size,etc.)
—
6 ft .S ft.
4.Date Well(s)Completed: Z)Well ID# S ft. / ft.
CXA-
5a.IWell Location: i f� 9 IL
ft.
Facility/Owner Name FacilityID##(if a plicable ft. ft.) ft ft
Physical Address,City,and Zip (� ft• ft
_�Lt,f� 38 4 a Z6 21:REMARKS J
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t' pronpssing U1111
(ifwell field,one lat/long is sufficient) 22.Certifi lion: DWIR Seddon
3S s1o35v N --8'O. 3 L!7 6'g3 W
6.Is(are)the well(s)i'Permanent or OTemporary Sig&eCri of ertified Well Contrac Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well• MYes or 10No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standmds 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-I is1eeded. 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: I C- (fL) 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'aul 2@100) construction to the following:
0
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 (in.) 24b.For Iniection 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: 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) Z 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: (.'1 ir44"t 4 r Amount ,O? 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