GW1-2021-02658_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. ell Contractor Information:
ca bvl 14.,WATERZONES':r-'.'
y FROM TO DESCRIPTION
Well CoScto}�iap 'n f 1 2021 ft
NC Well Contractor Certification Number 'yC' f - ;,etJ 1111� fL ft
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Ilil.�el'1,3�1+;j t' a•�.�'ti0n -15c�0UTERCASING.(formulti=ca'sedwelLi'OR•LIlVER{ifa' licatile--<€.-.:.i�::;.�:�`_.:
Morgan Well & Pump, Inc. [)i'vi-'���� FROM To DIAMETER Ti MATERIAL
+1 fL ft 61/8/ in' ad21 pvc
Company Name
�zr\� � 16 INNER CASING OR:TIIBIIVG`(`eother`mal'elos'ed�loo
2.Well Construction Permit#: `,,JJ C) lj D FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits i-e-UIC,Comity,State,Variance,etc.) fL ft
3.Well Use(check well use): ft ft
17:.SCREEN:;:::::.. ":=. :�.....:.:_._.; ;..=:.-;'-:>=s :�:.o �-..�_.-:::.
Water Supply Well: FROM . TO DIAMETER SLOTSIZE THICKNESS MATERIAL
J Agricultural [)Municipal/Public ft ft in.
J Geothermal(Heating/Cooling Supply) �esidential Water Supply(single) ft• ft.
Industrial/Commercial Residential Water Supply(shared) _
':18:GROUT.'-Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft Y0 ft. hentonite poured
Monitoring DRecovery ft ft
Injection Well: ft. ft
!Aquifer Recharge QJ Groundwater Remediation
.19.SANDIGRAVEL'PACK if
_ Aquifer Storage and Recovery O-•i Salinity Barrier FROM TO MATERLAL EMPLACEMENT METHOD
J Aquifer Test E2Stormwater Drainage fL fL
Experimental Technology Oi Subsidence Control ft ft
+Geothermal(Closed Loop) 13TracerZ1J.DRILLIlVG.LOG'{attach additional sheets:ifnacess );;:_;.: °:
FROM To DESCRIPTION(color,hardness,soiurock
i Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks type, rain size etc
l b ft. S ft ;,_
4.Date Well(s)Completed: 1 Well ID# 5ft ;ta ft TrI .?
Sa.Well Location: 2� ft. O ft. . .1 J S
Sd k 'FrtJCll a ft d ft vtan C�
Facility/Owner Name f
11 (� NFacility ID#(if applicable) 0 ft i1 U ft " rr
`� .
'Z63� V /�I eA J� 'M+ VtK) 611 Cc1A1 ' ft C/ ft
Physical Address,City,and Zip ��J\J\ I''/� fy//�� ft. ft
County Parcel Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well S field,one lat/lo a is sufficient) ' ,,�(Yj; W 22.Ce cation:
N: g Xvl+�
uy'vs��- Gl �oZ
6.Is(are)the well(OmPermanent or Temporary S�anature of Certi d 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: QYes or hkNo with ISA NCAC 02C.010o or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell out/onown 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 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: �® (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 c@200'and @1000 construction to the following:
10.Static water level below top of casing: ik (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: l 4 f y 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
n the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 610 Z completion of well construction to the county health department of the county
where constructed.
i
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016