GW1-2021-01571_Well Construction - GW1_20210309

- BUN RECORD
1. Weil Contractor inform
ation:
Chris Morgan
Well Contractor Name
3572
NC Well Contractor Certification Number
Morgan Well & Pump, Inc.
Company Name
2. Well•Constructian Permit:
WW-1
RECEIVED
MAR X 9 2021
inforrnaUon Processing Unit
DWR Section
WSJ
List all applicable cell co,tsrnrction pennus (i.e. UiC, County. State, Variance etc)
3. Well Use (checkssell use):
Water Supply Well:
Agricultural
Geothcnnat (Heating/Cooling Supply)
tI Industrial/Commercial
hrigation
Non -Water Supply Well:
Monitoring
injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
} Geothermal (Closed Loop)
rJCcothernial (Heating/Cooling Return)
4. Date Well(s) Completed: Z — I1 v14
IjMunicipal/Public
&Residential Water Supply(single)
DlResidential Water Supply (shared)
DlRecovery
Groundwater Remediation
DSaliniiy Barrier
I Stormwater Drainage
QlSubsidence Control
DlTracer
Other (explain under r:21 Remarks)
Well ID,r` n/a
Sa. Well Location:
Facility/Owner amc
16 Z$ ofa
County
n/a
Facility ID,, (if applicable)
Parcel Identification NT
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field, one Int/long is sufficient)
Sr7. 5.3ZtXS PI --go . S CM 22
6. Is(are) the well(s)C3Permanent or Df T emporary
?. Is this a repair to an existing D
If this is a,•e hng well: Ycs or i�'o
pal,; fill out /wow„ well constntction information and explain the torture of the
repair wider ti21 remarks• section or on the back of this fonn.
S. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
For multiple wells list all depths rfd�erent (example- 3 tt 200"and 3 @Iaa')
10. Static water level below top of casing: If hater level is above casing, use •• (ft.)
11. Borehole diameter: 6
12. Well construction method: rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR 1VAT R SUPPLY WELLS ONLY:
I3a. Yield (gpm)
Method of test:air Pressure
13b. Disinfection type: granular
W
(ft-)
For internal Use Only:
I4 _WATER ZONES
DESCRIPTION
IS. OUTER CASING (for multi -cased wells) OR L
INER(ifa
16. INNER CASING OR TUBING
Cnnnv __
17. SCREEN
FROM TO
rt.
IS. GROUT
D1ARiEfER
In.
SLOT SIZE
Livable)
MATERIAL
MATERIAL
THICKNESS
MATERIAL
EMPLACEMENT METHOD & AMOUNT
poured
11111111111111111
MATERIAL
ft. ft.
(attach additional sheets if necessary)
amitaim.-tavnr miLTO
1, v ft. .�} DESCRIPTION (color, hardness,
ess, milked: t e _rain sae,etc.)
.
u ft. q, DfoGa it b)
ft. S, r
it Itra�_
c . �rC
ft.
21. REMARKS
Z2. Certification:
4 AA/
EMPLACEMENT tiTETHOD
Signature ofCcrt 6d Well Contractor " W Zi
Date
By signing this fomr, I hereby certib that the wall(s) was (were) constructed in accordance
nilh ISA NC -IC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details;
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL LNSTRUCTIONS
24a. For All Submit this form within 30 days of completion of well
construction to the folloug:
Division of Water Resources, Information Processing Unit,
I617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection 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
construction to the following:
Division of Water Resources, underground injectionC t 1 Program,
1636 Mail Service Center, Raleigh, on 3o
NC 27G99-163b
24c. For Water Sunniv & Infection Welts: In addition to sending
the
to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
Fo to OW-1 where constructed.
North Carolina Department of Environmental Quality- Division of Water Resources
?mount: / g 07
Revised 2-22-2016