GW1-2021-02616_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
lAVell Contdryctor Informa'on: I
I
-:14.WATER ZONES
FRONL TO DESCRU'T10N
Well Contractor e q •i
,1 ' 2021 ft ft �
NC Well Contractor Certification Number S r N
15i'OUTER CASING,(fdr multi-cased•wells)-'OR LINER if a" licatile=
Morgan Well& Pump, Ul�it FROM TO DIAMETER Tall Ess MATERIAL
9 P , �e a j \
ft I V ft 61/8/ in. sdY21 Pvc
lit
Company Name �r.,:Cll /�
(.J L 16:INNER CASING OR.TIIBIIVG' eothe=mal.'closed400
2.Well Construction Permit#: FROM TO DIAMETER TffiCIINESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft ft Ain3.Well Use(check well use): ft ft
IEEE I
17::SCREEN::.::::..
Water Supply Well:
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'ilAgricultural []Municipal/Public ft. ft in. I
Geothermal(Heating/Cooling Supply) Di Residential Water Supply(single) ft ft in.
i
j .Industrial/Commercial Residential Water Supply(shared) 18 GRO1TT.. -
Irri ation FROM TO MATERIAL `EMPLACEMENT METHOD&.4MOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
J Monitoring QRecovery ft. ft
Injection Well: ft. ft
-J Aquifer Recharge rJJJ Groundwater Remediation -77-7
19:SANDIGRAVFL'PACK Cif a 'licable
J Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EVffLACEMENT METHOD
:)Aquifer Test !3 Stormwater Drainage ft. ft
J Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) Tracer l A DRIL -ENG.LOG{ittacli additional stieets:if
FROM TO DESC PTI (color hardness,soi0rock type, rain size,eta)
BGeothermal(Heating[Cooling Return) J Other(explain under#21 Remarks) tV ft t
4.Date Well(s)Completed:' 76'7.1 Well ID# ft ft. M U�
5a.Well occaption: J
�� L7 V41/4.�F✓ ./ ft 6 ft ir-As Tc
Faclity/Olity Nrwne�i ame Facility ID#(if applicable) ft ft
(,r i (�/�. �0/) 5�5�'i 0/� ft ft.
Physic 1 Address,City and Zip ft ft
lti �o3b6 _ .
County Parcel Identification No.(PlN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,onelaUlong is sufficient) (� 2 . rtification:
S, VP716 N g�•I l l LOP?-
7 W ::�b EX' 6 Z �
6.Is(are)the well(sAPermanent or Temporary S tore Certified Well Con for Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or with 15A NCAC 01C.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 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 needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: l— SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7,,yG C) (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3 r200'and 2Q100� construction to the following:
✓
10.Static water level below top of casing: C (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
fi v � ✓ above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: /�/�_�� 1` / 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
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: �4q'��Gl� Amount: A 40 7 completion of well construction to the county health department of the county
where constructed. j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources1 Revised 2-22-2016