GW1-2021-02376_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W Contractor Info on
C'J
_ .�W ATER'Z ONES' - DESCRIPTION :...:......:......... _ .. . .._..:...;. .
Well Con act- Name `
` A T% ft ft. f
q `' \� vYN ft ft
NC Well Contractor Certification NumberOUTER.CASING.(formulticssed'wells OR LINER if a' lica6le`='..:_`.<`=•'.' ..-
rOS+
Morgan Well & Pump, Inc. ; ���Ei° FROM To DIAMETER THICTavEss MATERIAL
O +1 ft ft 61/8/ in' sd21 pvc
Company Name �� o
C/�11, 7777
16'DWM CASING OR TIIBII�G `eothermsl'closed=loo i'
2.Well Construction Permit#: 1 �, FROM I To I DIAMETER THICKNESS MATERAL
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.) ft ft.
3.Well Use(check well use): ft ft in.
IV SCREEN -
Water Supply Well: FROM TO DIAMETER SLOTSiZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft in.
'JIGeothermal(Heating/Cooling Supply) aResidential Water Supply(single) ft ft in.
Industrial/Commercial —i Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EWL,&CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
'71Monitoring QRecovery ft ft
Injection Well: ft ft
!Aquifer Recharge QGroundwater Remediation
19:SAND/GRAVEL'PACK if a ,licatihi' .:'.:<':.':`:-.'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL FeMPLACEMENT METHOD'
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology OSubsidence Control ft ft
Reothermal
eothermal(Closed Loop) �j Tracer ?2`6.DRII LING.LOG{attacti additional stieets:if recess :'.
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc
(Heating/Cooling Return) J Other(explain under#21 Remarks) Q ft 20 ft
4.Date Well(s)Completed:7/1`7 Well ID# L0 ft lr
Well Lo on:
so
ft
Facility/ n 1 Name Facility ID#(if appli le) ft ft
��\ ft ft.
ft ft
sicaI Addr ,City,and Zip
`:-2L'REIvieRuc;,.:r,__,._. :.. .. ..:.:.. _...:: . -
tnY>t Y1 -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one I t/lo is sufficient) (,,rfj- �� 22.Cer' cation:
6.Is(are)the well(s)ipPermanent or OTemporary Signa f .itified Well Contractor a e
By si n'g i form,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EJ Yes or ®No with A N C 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 ofthisform. 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: 264) A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100D construction to the following:
10.Static water level below top of casing: (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 .) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
'p above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: "l construction to the following:
(Le.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
i
13a.Yield(gpm) 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 typ { 'b Amount: 00z completion of well construction to the county health department of the county
where constructed.
a
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016