GW1-2021-02638_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I
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14.WATER ZONES
Well Contractor Name �►`'�° FROM TO DESCRIPTION
ft
ft ` ft
NC Well Contractor Certification Number $611
in;OUTER CASING.(for multi=cased,ive➢s)OR'LINER{if
Morgan Well &Pump, Inc. t v� 4`n' ��SeCZ''OD FROM TO DIAMETER TffiCKNESS MATERIAL
6 +t ft ft 61/8/ in sdr21 pvc
Company Name
�(/J(r'f v U 16'INNER CASIN ORTIIBING' eotherm
FROM MATERIAL
TO DIAMETER
2.Well Construction Permit#: TRICKINESS
ft. ft in.
List all applicable well construction permits rz.e.VIC,County,State,Variance,etc)-
3.Well Use(check well use): ft ft in.
Water Supply Well: -. :.. ..:.. .,...: :-.:.; ...-.. . .:-.-- ......:__:...:-..,.::.. -..,
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS 14fATERLAL
Agricultural rIMunicipaUPublic ft. ft
I Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
i Industrial/Commercial Residential Water Supply(shared)
:18:GROUT..
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft PO ft bentonite poured
_E Monitoring QRecovery ft ft
Injection Well: ft ft
_ Aquifer Recharge E�7 Groundwater Remediation
19:SANDIGRAVEL-PACK if a lieable -
'Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
i Aquifer Test [3 Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) Tracer 52b.DRMLINQ.LO To G'{aitacti'additionalstieets:ifneccss
i Geothermal(Heating/Cooling RetuReturn)) J Other(explain under#21 Rem s) FROM DEse PTI (color,hardness soil/rock e,grain size,etc)
d ft ft 1
r
L 1.--LI
4.Date Well(s)Completed: Well ID#
5aAell__Location: —To—ft. ft
. 11Z UC',-\ S / �(� ft j 9S ft l�c t
ft. ft
Faci ty/// canner Name �f /� r Facility ID#(if applicable)
�+�+ c/DI1\ dCVk— �/ �/ L( awl/► `a ft ft
ft. ft
Physical Address City,and Zip /� G
611 LV AI O.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
S,`lq-1 Z N --9 li !��Q 7S' W l� Z Z Zo�
6.Is(are)the well(s) ermanent or OTemporary
Signature of ed Well 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: Yes or N0 with 15.4 NCAC 02C.0100 or 15A NCAC 01C.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 iGW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: i e` (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 200'mid 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 (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: ` �/ 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) 3 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: lr 4' Uw"' Amount: 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 i Revised 2-22-2016