GW1-2021-02637_Well Construction - GW1_20210723

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well.Cantractor form tion:
14.WATER ZONES
FROM TO DESCRIPTION
Well on ctor ame
ft. fL
NC Well Contractor Certification Number
J \�' 15i OUTER CASING(for multi=cased wells OR LINER if a lieatile`=:>._
t�rt3L�_' r FROM TO DIAMETER THICKNESS MATERU.L
Morgan Well& Pump, Inc. �:��\ rt,^
� � J 1()
16:IN1VER CASING ORTUBING'(`eo in' sdr21 pvc
ft ft
L6118/
Company Name �Y+
"thermal'rlo3ed-1o6
2.Well Construction Permit#: �VV�-C�/ FROM TO DIAMETER THlclavEss MATERLAL
List all applicable well construction permits(:.e. C,County,State;Variance,etc.) h R in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 171SCREEN:'; ' ';:; i.:.:: ..
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft in.
J Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) fL ft
i Industrial/Commercial Residential Water Supply(shared)
f18:GROUT.:
Irrigation FROM TO MATERLJ, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o fL 20 fL bentonite poured
_.Monitoring Recovery ft. fL
Injection Well:
fL ft-
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVIM`PACK if if "licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMELACEMENT METHOD
_)Aquifer Test Storrnwater Drainage ft ft
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer20.DRII.T�IGLOG{attachsdditionalstieets:ifnecess
FROM TO DESCRI TIO (col r,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) ft ft— 1
4.Date Well(s)Completed: 17L Well ID# �ft ft.
Well Location: ft. ft. r
fL t
I wire, ghne& I-=�3
acility/Owner Name d* Facility JD#'(if appliicabllle) ft ft
L 6014 V,1u-, 1' �Y. r 4J ��4 bSt) ft ft
Physical Address,
yCiity,and Q ft ft
:21:'REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one la?t/long is sufficient) 22. tification;
3�, U N "r Ft/ W V. 2---�>
_ ✓/
6.Is(are)the well(s)40 Permanent or 13Temporary a Certified Well Contractor Date
By signs` this form,1 hereby cenKify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or NNo 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 connstruction.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: 2L (ft.) 24a. For All Wells:' Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: D� (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in 24b.For Iniection Wells: In addition to sending the form to the address in 24a
J above,also submit one copy of this jform within 30 days of completion of well
12.Well construction method: \y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL 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
r J the address(es) above, also submit lone copy of this form within 30 days of
- r
13b.Disinfection typ Amount: 6t, completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016