GW1-2021-02538_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well fontractor Inf rmation:
� 3 --14.WATER ZONES ._
Well 4�o�_ s_tee \ O FROM TO DESCRIPTION
N ^ ft ft
n 1.
NC Well Contractor Certification Number V\v 0�$$\ri-.3 15.OUTER CASING for mnitl cased wells OR LIIVER if a livable
Morgan Well &Pump, Inc. tb�`p�oec�;o� FROM TO DIAMETER THICKNESS MATERIAL
``J V +t ft '{ ft 61/8/ in' sdf21 Pvc
Company Name ..16:INNER CASING OR TUBING 'eothermal closed-loop)
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(tile.VIC,County,State,Variance,etc.) ft ft +in3.Well Use(check well use): ft fL17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) fL ft in.
_Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft bentonite poured
Monitoring Recovery ft ft.
Injection Well: ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_.Aquifer Test Stormwater Drainage ft ft
Experimental Technology n Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 1"26.DRILLING LOG attacli additional sheets if necess r `::.
Geothermal(Heatin .Cooling Retum) Other(ex lain under#21 Remarks) FROM To DESCRIPTION wtoq hardness soil/rocka rain siu etc.)
— '� ' b ft io It fo 1
4.Date Well(s)Completed:lit
I D7i 11 Well ID# Ito ft `, 50 ft mat- ,rY,
3 s ✓�
5a.Well Location: 3b ft 2 J& ft. 604n rOck
ft p ft t ✓.�
Facility/Owner Name 'rr� L ) Facility ID#(if
papplicable)
j � L►(zo ft f✓{ , D' 141!IL "(1XYN -1c,
i'rT l�� �t�il " �'//� ^v I��/.JIL.I' ifN ft. il ft. �11/� 1(Q�ib�
ft ft
P sical Address,CIty,and Zip
r v
21:REMARKS -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. Ication:
'7:�S,35 22, -N W %�- � '5L21 /21
6.Is(are)the well(s)oPermanent or OTemporary Signa f ied Well Contractor Dale
By signing t form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or DNo with 15A NCAC 02C.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#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: SUBMITTAL INSTRUCTIONS
/a
9.Total well depth below land surface: CtI!D� A) 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@1001 construction to the following:
10.Static water level below top of casing: t_d 0 (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: 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&Iniection Wells: In addition to sending the form to
Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: !3 Oli 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