GW1-2021-02369_Well Construction - GW1_20210723

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only-
I.tWep Contractor formation:
a. 14.WATER-ZONES'::: ':' t'.: :i r.;.
Well Contractor Name ` FROM TO DESCRIPTION
�®
r� Z ft ft.
(.��� ft ft
NC Well Contractor Certification Numberso
15i OUTER CASING.for multi=cssen we➢s)OI2'L1NER if a' liratile`;'.:"::'`;:•'.,'
Morgan Well & Pump, Inc. `.�K000 FROM TO DIAMETER THICFNESS MATERIAL
e' ` n +1 ft. 6S ft 61/8/ in. sd21 pvc
Company Name
l/ �`a '�003
16I$INER CASING OR.TIIBIIVG' `etitheimal:elosed=lob "
2.Well Construction Permit#: FROM To DIAMETER THICIavEss MATERIAL.
List all applicable well consA•uction permits ri.e. UIC,County,State,Variance,etc.) ft ft rn'
3.Well Use(check well use): ft ft in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft
Geothermal(Heating/Cooling Supply) W1 Residential Water Supply(single) ft ft
i Industrial/Commercial DResidential Water Supply(shared)
... .. . ....:.
hri ation FROM TO 'MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
_:Monitoring Recovery ft. ft
Injection Well: ft ft
_!Aquifer Recharge �J Groundwater Remediation
19:SAND/GRAV1WPACK Cd a` icable
Aquifer Storage and Recovery MSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
i Aquifer Test Stormwater Drainage ft ft
J Experimental Technology OSubsidence Control fa ft.
Geothermal(Closed Loop) Tracer it 2b.DRILLING..LOG'fitti6 iddiddii sfieets:if necess '
i Geothermal(Heating/Cooling Return) (ex) i plain under#21 Remarks)
FROM TO DESCRIPTION(color,hardness,soil/rockitype, rain size,etc)
ft 1 ` ,ft, ft 3o f p I ;f+-
4.Date Well(s)Completed: t Well ID# t W^ b•r'
5a-Well Location: '& ft. C ft S64+
J G(kmo rc— 'Deve(r prie ic-- Cj ft ft
Facility/Owner Name Facility M#(if applicable) 9 S ft Ct ft rV r A^,
I yo l vC a9 NwY ft ft-
Ph s'caI Address,City,and Zip ft ft
;..
_ � cl n:A a,0--- 94o?�56�1-'I�
':21:RE1v1ARKS�->:�-; ,' . :.:::..:.:: ...�.. __..:.. ..:. ..:.:.. ..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
-y(if ecll field,onnee�latt//lloongg its sufficient) �GG� /� �J 22- a cation:
V- (. A ( 0 �/� N — / I•�V6 ? W
6.Is(are)the well(s)&§Permanent or OTemporary Signature of Cerf e0 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: Dyes or Wo with 15.4 NCAC 02C.0100 or 15,4 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: z W SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 yO (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a200'and 2@100� construction to the following:
10.Static water level below top of casing: yV (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
�O4/`Y 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,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
m 13a.Yield
(gp ) Method of test:
2 d air pressure 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit i one copy of this form within 30 days of
131b.Disinfection type:6*-<.t,.o1&_,— Amount: lot, 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