GW1-2021-02356_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. ll Contr ctor nformation:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION'
S � � Jfc ft
— 9 ^ ft ft
NC W—ell Contractor Certification Number I uL �j O �O� rt 15c OUTER CASING.(formulti=csseH wel(i OR LINER -
Morgan Well & Pump, Inc. J SS�nJ U OM TO DIAMETER THICKNESS MATERIAL
+1 ft 1 ft 6 1/81 in' sdr21 pvc
Company Name MATERIAL
L.
' 16:INNER CASING OR.TUBING"`eotheima`1`closed=loob:' _ ...-.
2.Well Construction Permit#: FROM TER THICKNESS MATERIA
List all applicable well construction permits CET WC,County,State,Variance,etc.) ft TO DIAME fr. in•
3.Well Use(check well use): ft. it.
171SCREEN::,'.::.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft ft
71 Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft
Industrial/Commercial Residential Water Supply(shared)
':18:GROUT.:.'
`Irri ation FROM TO MATERIAL r,EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring Recovery ft. ft
Injection Well: ft ft.
_!Aquifer Recharge Groundwater Remediation
19:SANDIGRAVEL`PACK rfa 'licabl`e
Aquifer Storage and Recovery DSalinity Banter FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer z1!b.DRiLL1NG..LOG'{atti6 additional slieets:ifnecess
i Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPT[ N(color,hardness,soil/rock type,gmin size,etc.)
/J/ ft ft e ;r
4.Date Well(s)Completed: '• r of Well ID# 6 ft. 6, fr. (—�� L�
5a.Well Location: ft. -L94.1 ft.
V�V / I'iC!/►9��N' i"' ft 4Q ft ✓a', l'L�
Facility/Owner Name / Facility
�ID#(if applicable)
I L d ft 76 O ft
ft ft
Ph y'cal Address,City,and Zip ft ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one9flng iOs suffi�ent) � 22 u. �? FU l
N W Z(
6.Is(are)the well(s)S Permanent or OTemporary Signature of Certified VATContractor 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: QYes or SLNO with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell out known well construction information Ad 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 G 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: It SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —760 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welLs list all depths ifdi)jerent(example-3@2 //nd��2@100q construction to the following:
10.Static water level below top of casing: 7V y (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Labove, also submit one copy of this form within 30 days of completion of well
12.Well construction method: l r 1 U�( � construction to the following:
(i.e.auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 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: "" Amount: C.� (/ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016