GW1-2021-02614_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor nformation:
.r:14.WATER ZONES" :- -
FROM TO DESCRIPTION
Well Contractor Name
9 ft J ft
NC Well Contractor Certification Number d 1 -
J `�Opr'03 1 FROM ft TO (ft DIAMETER
OR LINERS hMATEIZIA..
1)'n 15.OUTER CASING.for multi=cased'
Morgan Well& Pump, Inc. R Tr�clavEss MATERIAL
_4%AA �2 in- sd21 pvc
Company Name
/' t �/ 16ANNER CASING ORTJBING`-eotheimal.'do'E 400
2.Well Construction Permit#: (y., w ` `J(, / FROM TO DIAM in.ETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc)- ft. ft.
ft ft in.
3.Well Use(check well use):
IV—SCREEN:
Water Supply Well: FROM TO DIAMETER SLOT STZEL THICKNESS MATERIAL
Agricultural [3Municipal/Public ft ft in.
J Geothermal(Heating/Cooling Supply) 4gResidential Water Supply(single) ft in.
I Industrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METTiOD&.AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring QRecovery ft. ft
Injection Well: ft ft
!Aquifer Recharge QGroundwater Remediation
19:SANDIGRAVEL'PACK rf a liiable Aquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test [3Stormwater Drainage ft ft
_;Experimental Technology Subsidence Control fL ft
Geothermal(Closed Loop) Tracer 9 ZO.I PJLLING.LOG'(attiih idditioual sheets:if ieaSs
i Geothermal(Heating/Cooling Return) .J Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock size,e,grain etc.)
O ft ft b,'—
zr�-z1 oi.3rL l�t�
4.Date Well(s)Completed: ' Well ID# S ft v ft. '�.
5a.Well ocation: ) p ft ft- 11
ft 3 S ft
Facility/Owner Name Facility ID#(if applicable) ft ft.
Z�30 O V S e—r f 1�— Pm y C`e- ft ft
ft ft.
Physical Address,City,and Zip
om%Ll/1 i✓� �ti 21:REIVI:ARKSrs . -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 4 22.Certification:
04 —
fir' 2 t
6.Is(are)the well(s)aPermanent or Temporary
SljTofure of Certified V a Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [2Yes or J@No with 15A NCAC 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 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5_5 ft 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a 2 'mid 2@1001 construction to the following:
10.Static water level below top of casing: 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
ll.Borehole diameter: 6 (in.) 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: /"��j f tPL92�C construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
LLS 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
the address(es) above,also submit~one copy of this form within 30 days of
13b.Disinfection type:C7�4�L,Za✓ 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