GW1-2021-02375_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well C tor Info 'o q��I
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14.WATERZONES'::=`.'
FROM TO DESCRIPTION
Well Co acto ame \ C) 'a � \\l ft ft I
ct J� r r r L Z,On 15:'OUTER CASING.for multi=rased`wells'OR NC Well Contractor Certification Number 4 I I
t yE, LTNER if a' licatile=•�'.:._:_`>.,.:..
Morgan Well & Pump, Inc. ���c� L�Z ' FROM TO ( DIAMETER THICKNESS MATERIAL
+1 ft ft 61/8/ j in sd21 pvc
Company Name ,/� J[CINNER CASING ORTUBING`'eothei mal'.dosed=lod'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)- ft ft in.
3.Well Use(check well use): ft ft in.
iZ:'.SCREEN '. V.
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Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �Municipal/Public ft. ft �•
J Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft. ft in.
Industrial/Commercial �Residential Water Supply(shared)
18.GROUT..*_`.. —
Iln ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring QRecovery ft ft
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
.19:SAND/GRAVEL'PACK if a livable)*
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD'
_I Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology OSubsidence Control ft ft
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Geothermal Geothermal(Closed Loop) Tracer 12b.DRELLING {aita'di sh'eats`
.LOG' 'sdditioiial :if ueces )','_
FROM TO DESCRIPTION(color,hardness,sail/rock type, rain size,etc
Geothermal(HeatingLCooling Retum) i Other(explain under#21 Remarks) 0 ft �C ft
4.Date Well(s)Completed: Well ID# ft ft. R' tt�
5a.Well Location: ft. ® ft.
0 ft VtO ft-
Facility/Owner Name Facility ID#(if applicable) ft ft
ly
f� � l� � ��� ft ft
al Address,City,and Zip ft ft
".:11'REN ARKRj'_':=_-;
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) p Jg
tie .
6.Is(are)the well(s)&Permanent or OTemporary ified Well Contractor at
form,I hereby cer fify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or MNo C 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 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:2D (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-/3Q200'a»d 2Q100� construction to the following:
10.Static water level below top of casing: (ft) Division of Water Res oul ces,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 n.) 24b.For Iniection 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: construction to the following:
(i.e.auger,rotary,cable,direct push,a c.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c..For Water Supply&Injection Wells: In addition to sending the form to
13 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection typ kUra� Amount: completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016