GW1-2021-02665_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well •actor Informa on:
C'J J t, _ 14.WATER ZONES
Well Co tract Name ) j W FROM TO DESCRIPTION'
'S ft ft.
` ( 1 20 61 ft ft
Stp 1.
NC Well Contractor Certification Number
i�`ci.l�,J 31l 15::OUTER CASING(for multi-cased'wells)OR LD`IER if a"licalile
Morgan Well & Pump, Inc. ;'rot FROM To DIAMETER THICENESS MATERIAL
,r4no�'h',:3ie,I-t `>r,nrt +1 ft e� ft. 61lS/ in.
V1 sd21 pvc
Company Name
16:INNER CASING OR TUBING 'etitlie'rmal
2.Well Construction Permit#: I FROM TO DIAMETER THICKi`IESS MATERIAL
List all applicable well construction permits fl.e.TWC,Coun v,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: FROM TO DIAMETER. SLOT SIZE TATCKNESS .MATERIAL
-':Agricultural r.IMunicipal/Public ft. ft in.
:]Geothermal Geothermal(Heating/Cooling Supply) SResidential Water Supply(single) ft g in,
i InduStrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring QRecovery ft. ft
Injection Well: ft
-_!Aquifer Recharge r 11 Groundwater Remediation
19:SAND/GRAVEL PACK licatili: ,
Aquifer Storage and Recovery [ISalinity Barrier FROM TO MA RIAL I EMPLACEMENT METHOD
_i Aquifer Test [3Stormwater Drainage ft ft
J Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) [ITracer 20.DRILLING.I:OG(attad5'additidnal sheets if neces
FROM TO DESCRIPTI N(e g lor,hardness, 1/rock type,grain size,etc.)
J Geothermal(Heating/Cooling Return) _I Other(explain under#21 Remarks) p� ft ft.
4.Date Wells)Completed: I Well ID# ft
5 Well Locatio ft
ft. ft
u
acility/ weer Name Facility ID#(if applicable) J ft ft / . s.L-
n l�P( ft ft. l
Ph Address,City and Zip L- ft ft
Wain
County Parcel Identification No.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fiend,one lat/long is sufficient) jj 22.Cersfiat91tionl
:1t7 � N _ t � l W
6.Is(are)the well(s) 'Permanent or Temporary Sign Certified Well Contractor Dad
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: Yes or MNo with 15A NCAC 01C.0100 or 15-4 NCAC 01C.0100 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 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 2 • (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@22,00'and 2@100D construction to the following:
10.Static water level below top of casing: 2—to (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 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
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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
air pressure 24c.For Water Supply&Injection Welts: In addition to sending the form to
13a.Yield(gpm) `) Method of test: g
Je(��yy� the address(es) above, also submit`one copy of this form within 30 days of
13b.Disinfection type Amount:7 V 67. completion of well construction to 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