GW1-2021-02667_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I
WellContractorName FROM TO DESCRL?TiON
57 �f nn i I Z6 fL tZ ft i
ft ft
NC Well Contractor Certification Number e 2021
S t P /1\ � -15-OUTER CASING(fors tirniti=casedwells)-'OR LINER{if a licafile
Morgan Well &Pump, Inc. FROM I TO nIAMETEA THItnrnFss MATERIAL
1 11 +1 ft 6� ft 1 61/8/ iin. sd21 pvc
an
P Y
Corn Name �!a vs .l'sit1:i t •."'•.. "' _-
1`if. r_.,N"i _ ..
� �,, _ t•Orl 16:INNER CASING OR TUBING -eotherma`I'dos'ed=loo
2.Well Construction Permit#: 341 1 FROM To IDIAMETER I TffiCKNESS •MATERrer.
List all applicable well construction permits fl.e.UIC,Counry,State,Variance,etc) ft. ft in.
3.Well Use(check well use): ft ft in.
17_".SCREEN
Water Supply Well: 4.t.
Pp Y FROM TO DIAMETER SLOT SIZE THICICNFSS MATERIAL
J Agricultural QM icipal/Public ft. ft �•
J Geothermal(Heating/Cooling Supply) R<sidential Water Supply(single) fL ft in.
hrdushial/Commercial Residential Water Supply(shared)
GROUT.:
Irri ation FROM TO MATERIAL EMPLSCEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL bentonite poured
Monitoring DRecovery ft ft
Injection Well: ft ft
Aquifer Recharge []Groundwater Remediation . . -. ..
19:SAND/GRAVF.L`PACK(if a licalilb .-:<'..:is.•;;'::;,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft.
Experimental Technology Subsidence Control fL fL
Geothermal(Closed Loop) Tracer °l 2i1.DRII.LIlVG..LOG ittiii6'idditid6l sEe'6-ifE iiecess s':':
Geothermal(HeatinglCooling Return) n Other(explain under#21 Remarks) FROM TO DESCRIPTION(wior,hardness,soil/rock type,grain size,etc
a ft 36 Clout
4.Date Well(s)Completed: Well ID# 3 1 ft 60 H'
ft ft.
Sa.Well Location: 160
"(—( ft ft
,+ �����Facility/Owner Name Facility ID#(if applicable) ft ft
Yg15 nW4�c r^r Apt. �wl��ddy I IvG t-91,46 ft ft.
Physical Address,C and Zip 1 9 ft ft
`.;21:RRMARKR;�;':
bit 6K
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellfield,one lat/long is sufficient) 22.Certification:
�s•6t OcSGJ N �BD• c WO.-� J/—,
7"ZI—Z�
6.Is(are)the well(s) Permanent or 1 Temporary Signature of CertifiedOle."tractor 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: OYes or 2<o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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-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: 160 (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: 2,45 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
(� I above, also submit one copy of this form within 30 days of completion of well
n,
12.Well construction method: Iy 644 construction to the following:
(Le.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 submA one copy of this form within 30 days of
13b.Disinfection type: C616►tom Amount: 7d7— 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