GW1-2021-02671_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W etor I rma.
I < 14.WATER ZONES. -
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WeIIC tra orNa e c FROM TO DESCRIPTION��
ft. ft
NC Well Contractor Certification Number n �3i 'I7 t�Iq I5;'OUTER CASING.for mnlh cased'
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�i'D�vF1 r,r'1i01) ( webs 0R'L^II�R if a' hiable`;;..:;':<
Morgan Well & Pump, Inc. FROM I TO DLSMETEI THICKNESS MATERIAL
+1 ft. ft 51/8/ in. sd21 pvc
Company Name ' ;.
16:INNER CASING OR.TIIBING``eothermal:clos`ed400 :
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft. in.
17::SCREEN::.:.:.; . ;= .
Water Supply Well: :-.,<_r:.._:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic fL ft
J Geothermal(Heating/Cooling Supply) JEResidential Water Supply(single) ft
i Industrial/Commercial OResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft 20 ft bentonite poured
Monitoring ORecovery ft. ft
Injection Well: ft. ft.
I Aquifer Recharge QGi'oundwater Remediation
19:SANDIGRAVEL'PACK if a `licatile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EiY1PLACEMENT METHOD
i Aquifer Test E3 Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer ''2b.DRUI]NG.LOG'fil ticti'bdditional sheeti=if aecesis`'-)-' `': .
ex FROM To DESCRIPTI N(mlor,hardness,soil/rock a rain size,eta)
'Geothermal(HeatingXooling Return) lain under#21 Remarks
(explain) _ ) b ft t. ft k' d
4.Date Well(s)Completed: Well ID# 0 ft 34:5- ft U
LJJn
��eyqllLocati �/ ft. �5 ft �Iro
5a,
� e Y, �s' ft 5 ft
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Facility/Owner Name Facility ID#(if applicable) it. ft. J
t
I i c it. ft
cal Address,City,and Zip ft ft
.. ':21'REMARKS%"_'x_
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
z(ifwell field,one IaUlona is sufficient) (I 2e - tion:
6.Is(are)the well(s)4'Permanent or 13Temporary SigoOWrtified 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: ayes or MNo with 15.4 NC-AC 01C.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 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeRb,7,
a PT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
con! 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 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 1fdiIferent(example-31Q+200'and 2@1000 construction to the following:
10.Static water level below top of casing: 4-b (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniecion 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
m 13a.Yield
(gp ) 2— Method of test: air pressure 24c.For Water Supply&Iniecti In Wells: In addition to sending the form to
- It . the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection typo: ' > Amount: 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