GW1-2021-02383_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1. ell Contractor Information:
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14.WATER ZONES
Well C torName n FROM TO DESCRIPTION
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NC Well Contactor Certification Number 15.OUTER CASING.(for mtilti=cised;wdls OR LINER if a"
CJ Cit FROM T DIAMETER TffiCKNESS MATERW�
Morgan Well &Pump, Inc. �,�� ,c� e
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Company Name ^ /) 0614
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J' L 161INNER CASING OR.TIIBWG' eothe�mal:closed-lob
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2.Well Construction Permit#: FROM To DIAMETER I zHIclavEss MA't'F'Rrnr.
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.
17'.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public M ft in.
GGeothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft ft
i Industrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
'.Monitoring QRecovery ft. ft
Injection Well: fit. fit.
I Aquifer RechargeGroundwater Remediation
19.SANDIGRAVEL'PACK if a `livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft
Experimental Technology nSubsidence Control ft ft.
Geothermal(Closed Loop) Tracer 2b.DRILLING..LOG'{a[ts'cli-additionalslieets:ifnecessa"')':::'.:
EGeothermal(HeatinglCooling Return) i Other(explain under#21 Remarks)J
FROM To DESCRIPTION(color,hardness,sail/rock type rain size,etc
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4.Date Well(s)Completed: ' Well1D# ft ft. �-N kbck
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Well Loca on: fit. lG7�ft. l . .
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acili /O ner ame Facility ID#(if applicable) fit fit.
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S&JA Physical Address,City,and Zip fit fit
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(ifwell field,one lat/long is sufficient) 22.C rtific9
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6.Is(are)the well(s)*Permanent or OTemporary of Certified Well Contractor
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Vi.6g this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: O Yes or J@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 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: ' ('9, (ft-) 24a.'For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(erample-3(100'wand 2@100D construction to the following:
10.Static water level below top of casing: ` J (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
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above, also submit one copy of this?form within 30 days of completion of well
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12.Well construction method: 1 t 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
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 lone copy of this form within 30 days of
13b.Disinfection typ Amount: 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