GW1-2021-02372_Well Construction - GW1_20210723

i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ntractor
�D 14..WATER ZONES
Well Co tractor 4.e FROM TO DESCRIPTION
s° `a rlo�1 ft ft
V 1• ` ft ft i
NC Wel Connector Certification Number
�rr}Si 15:.OUTER CASING(for multi-rased wens)OR LINER if a" lieatile
Morgan Well &Pump, Inc. taar� GecZ<0 FROM T DIAMETER THICKNESS MATERIAL
^�" t2
\�A Jrt �• 16:INNER C' OR TIIBING e, rn sd21 pvc
Company Name
^��'� iithermal cloCMgEd A
2.Well Construction Permit#: L\�"�,�+'•//� � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.WC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft fL in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE TmCKNFSS 'YMATERIAL
Agricultural rlMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft• fr• in.
I Industrial/Commercial Residential Water Supply(shared)
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• bentonite poured
Monitoring Recovery ft. ft.
Injection Well:
p�,� ft. ft
__!Aquifer Recharge �Groundwater Remediation
.19:SAND/GRAVEL-PACK if a 'licalile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft ft
J Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20:'DRILL'NG..LOG(attacli'additidnal sheets if iiecess" ')':•_ Y.:. :
Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) rain size,etc)
FROM T O DESCR[PT[ N(color,hardness,soiltrock type,� — 6 ft ft. r'
4.Date Well(s)Completed' 0/�lid Well ID# 1 ft. ft
Sa.Well Lora' ` 'L G ft ft
ft. ft Nut, amh
Facilit//O� a Name Facility ID#(ifapplicable) ft ft
3`. � ft. fr.
tsical Address,City,and Zip ft. ft.
Kin itH
ty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfi Id,o e o ssufficient)
49
N—� ta7 W 22. tiff ;z)
�
2
6.Is(are)the well(s) Permanent or QlTemporary Si, Certified Well Contractor D
BJ sign this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or §No with 15A NCAC 02C.0100 or 15A 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 ow?rer.
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 I 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 ifdifferent(example-3@300'and 2@100D construction to the following:
10.Static water level below top of casing: {,j n (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 in.) 24b.For Injection 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: 6CA 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
air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
An.Yield(gpm) Method of test: g
the address(es) above, also submitl one copy of this form within 30 days of
13b.Disinfection typ : Amount: Y6 completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016