GW1-2021-02650_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
1.Well Contractor Information: c
14.WATERZONES:-
Well Contractor Name �';y. d M TO DESCRIPTION
Wla 1 i 2021 y ft. ft.
NC Well Contractor Certification Number r Oc}itr`J
OUTER CASING.for =cased wells OR LINER multi
FROM TO DL4METER THICKNESS MATERIAL
Morgan Well & Pump, Inc. t.,,�t�,3• ,�,r,.:;.`3 Q{ ft 61/8/' .
16:'INNER CASING ORTIIBING` ed in. sd21 Pvc
Company Name
/ 11 ..th'ecm's`I'elos'eg�loo� ;::�:: ..,." :...�
2.Well Construction Permit#:WCa"-C S"Z07+1� '5o7� FROM TO DIAMETER TffiCKNESS MATFurnr.
List all applicable well construction permits(i.e. UIC,Comity,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
1 17'.SCREEN
Water Su
PP Y Well: FROM TO DIAMETER SLOT SIZE+ THICKNESS MATERTAL
Agricultural OMunicipab?ublic ft. ft in.
J Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
1ndustrial/Commercial DResidential Water Supply(shared)I Irrigation FROM TO MATERIAL — EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
_Monitoring Recovery ft ft.
Injection Well:
i Aquifer Recharge n Groundwater Remediation
.19:SAND/GRAVEL'PACK if a `licabl`e`.',
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft ft.
!Geothermal(Closed Loop) [3Tracer 20.DRILLIIVG.LOG-(ittach-idditional964Fiti-ifEicess ':`:::'' ''==
i Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks)j FROM To DESCRIPTION(color,hardness,soiUrock type rain size,etc.
Q ft ft 10,.-
4.Date Well(s)Completed: " Well ID# (eft O ft 13 f0" [G`
5a.Well Location:
1// +0 r+CA /tivf t,s ft fz
facility/Owner Name Faci ity ID#(if applicable) ft
/ ft.
1.ro,4� 0-3 A
I Iq�deft ft ft
Physical Address,City,and Zip ft ft
'gkgw b4 �76o�6Qg 3oS'
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.Cer cation:
6.Is(are)the well(s)iq Permanent or OTemporary Signature of Certified�WeHlCoutractor Dat
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: QYes or V'No with 15A MCA 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.n ded. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: Jam• SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (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'imd 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 casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.Z 24b.For Iniection Wells: In addition to sending the form to the address in 24a
j a r "� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(ie.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: rlv W Amount: b Je completion of well construction toi 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