GW1-2021-02065_Well Construction - GW1_20210620

.DLALL CONSTRUCTION RECORD (GW-1) For intemal Use Only: v
1.Well ContractorIttformation:
Chris Morgan 14.WATER ZONES
Well Contractor Name FROb1 TO DESCRiP1710N
3572 ft.
ft. ft.
NC Well Co�tiractor,Certification Number 15.AUTSR CASTING(for malti cased wells OR LINER(iC. ncable)
Morgan"Weil&Pump, Inc. Front DIAMETER rslcicNFss minrctunL
61/8 t° sd27 pvc
Company Name
M � 16.INNER CASING OR TUBING( eothecmat closed-loci))
2,Well Cunstructian Permit#: ( (�1 v �• r•Ront To DLiMETER TxtcxNrss 'MATERIAL
List all applicahle well constriction pennies(i ce UIC,Conner.State,Variance,etc) ft. Ft. in.
3.Well Use(check well use): ft. R. —in.
Water Supply Well: 17.SCREEN —
I R0M TO DIAMETER SLOT SIZE THICIMSS HATERIAL
Agricultural DMunicipal/Public ft. ft In.
[Geothermal(Heating/Cooling Supply) ELResidenfial Water Supply'(single)
Qllndustrial/Commercial DResidential Water Supply(shared) ;a GROUT
Irrigation FROM TO MATERL!31, EM1iPLACENIEN"r,',IrTlioD&AMOUN7
Non-Voter Suppiv Well: o fL 20 ft. bentonite poured
I14onitoring ORecovery ft, ft.
Injection Well: —
ft. ft.
;Aquifer Recharge DGroundwater Remediation _
A uifer Storage and Recovery 19.SAND/GRAVEL PACIC(if licahlc)
9 $ ery []ISalinity Ban ier FROM TO RATERiAL F111PLACENIENT MET140D
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology QlSubsidence Control ft. ft. —
Geothermal(Closed Loop) QlTracer 20.DRILLE NG LOG(attach additional sheets If necessary)
Gcothemial(Heating/Cooling Return) 00ther(explain under 021 Remarks) FROA1 To DESCRIPTION fcalo,hnrdnecs,soil/ruck type,errla size,etc.)
ft. ft.
4.Hate Well(s)Completed: 2�'�'1 Well1ZY#n/a Jr
it. �� ft. i
13 own. `r
5a.Well Location: ft. 7�
U'� a✓ C•t✓._ nla 'U ft. fY. CX re G a
Facility/Owner Namc Facility ID-,(ifapplicabie) ft. ft.
>~
P" C) Gn u vt-s ft. ft. -
Physical Address,City.and Zip
ft. ft.
//
LI4 Ce�A_ rim- 21.R'EMAMKS
County Pan:cl Idcntificatinnilo_(PIN)
U
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 10GL'SStt1�
(ifxvell field,one lat/long is sufficient) 22.Certification: ire [}�,rvC�5eG
3 �� S�3 N �-�G.`lq�`j�!'1 W 1/� , ,-- M kY 2 L 261
6.ls(are)the wells).n Perinanent or [Temporary Signature ofCcrtif:Ed Well Contractor Date
Bp signing this fora.I herebi,re 0 that the mills)ivas(were)constnieted in accordance
7.Is this a repair to an existing well: [)Yes or n NO with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair fill out 6-nowl well constniction iAfonnaiimn and explain the nature oftha copy of this record hat been prvvided to the well oumer.
repair under 4'21 remarks section or on the back of ilrisform. 23.Site diagram or additional well details:
S.For Geoprobe/fDPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 GyV-1 is needed. Indicate TOTAL,NUMBER of wells construction details. You may also attach.additional pages if necessary.
drilled: ' l SUBMITTAL I?gSTRUCTIONS
9.Total well depth below land surface: (f") 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple%•ells list all depths ifdierent(erample-3@200'and 2@1001 constriction to the following:
10.Static water level below top of casing: 5 (€t.) Division of Water Resources,information Processing Unit,
ljtcater level is above casing,rise•'4-" 1617 Mail Service Center,Raleigh,PIC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Welts: In addition to sending the forth to the address in 24a
rotary 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,112aheigtt,NC 27699-1636
13a.Yield(gpni) Method of test: air pressure 24c.For Water SuoDhr&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.Disinfectiion type: granular Amount: IZo Z completion of well construction to the county health department of the county
where constructed.
Foot OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016