GW1-2021-02371_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) [Flortema�iuse Only:
1. ritractor In ti in:b14.PATER ZONES 1:
Well on. ct �o FROM ft ft.TO DESCRIPTI I
ON
.®G N
2 � „
ft ft
NC Well Contractor Certification Number d
\\� � \� 15:.OUTER CASING(for'multi-cased'wells)OR LINER if a''licalile=j. "
Morgan Well &Pump, Inc. USES\�� FROM TO DIAMETER TMCRNESS MATERIAL
+1 ft s421 pvc
Company Name �
16:INNER CASING OR TIIBING `eotlie'rmal closed-loo .'` :.. ' - • -
2.Well Construction Permit#: Fa1ra' � FROM TO DIAMETER THICEiYF.SS MATERIAL
List all applicable well construction permits fl.e.UIC,County,State,Variance,etc.)• ft ft. in.
3.Well Use(check well use): ft ft. in•
17.'SCREEN':.:
Water Supply Well: FROM TO DIAMETER SLOTSTZE TATCKNESS MATERIAL
Agricultural [IMunicipal/Public ft ft in•
i Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft
I Industrial/Commercial Residential Watei Supply(shared)
I8.GROUT:
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring ORecovery ft ft .
Injection Well:
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL'PACIC if a licatile .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test [3Stormwater Drainage ft ft
J Experimental Technology Subsidence Control ft ft.
_i Geothermal(Closed Loop) ['Tracer (
20:DRTLLING..LOG attacli'sdditidnal sheets if
necess :' - ,
FROM TO DESCRI TI N(color,hardness,soil/rock type, rain size,etc.
'Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) 2-0 ft r a
4.Date Well(s)Completed: / Well ID# �� ft.
G"0 ft ft . �Q �t . . -
5 Well Locatiorr}��• c..�
`� ft t��ft
tacility/Owner Name f r6 Fa ility ID#(if ap 'cable) ft. ft `J�
al Address,City,and Zi ft ft.
Wen3 _21:I2EMARKS: - _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/1 ng is sufficient) r��\` 22. ertification:
N" O0,`1®.2 w 0
6.Is(are)the wells)*Permanent or OTemporary Si of Certified Well Contractor e 1
g 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 ®No with A NCAC 01C.0100 or 15A NCAC 01C.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 421 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: _ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a 00'and 1Q100) construction to the following:
N. 10.Static water level below tap of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in. 24b.For Injection Wells: hi 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
pressure 13a.Yield(gpm) Method of test: air p 24c.For Water Supply&Injection 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 I ti VW Amount: Q 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