GW1-2021-02527_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD GW For Internal Use Only: Print Form
1.We ntractor Info ation:
�,0�� ��\` 14.WATER ZONES .:
Well O`n'�cto ame \� e�y`� FROM ft TO ft DESCR1PT10N
�v",6:1� ft. ft
L�
NC Well Contractor Certification Number
;'J -�� 15.OUTER CASING for muld-cased wells OT LINER ifs` liciible
Morgan Well& Pump, Inc. \�jry O FROM TO DIAMETER THICKNESS MATERIAL
+1 ft I&S ft 61/8/ in' sdf11 Pvc
Company Name
rr n -16:INNER CANDTG OR TOBING "-eothermal dosed466
2.Well Construction Permit#: 20
Q / FROM To DIAMETER TI�cIOVEss MATERIAL
List all applicable well construction permits(.e.UIC,County, rate,Variance,etc.) M ft In.
3.Well Use(check well use): ft ft in.
17.Water Supply Well: FROMCENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT_
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p M 20 ft bentonite poured
Monitoring .Recovery ft ft
Injection Well:
ft ft
_Aquifer Recharge OGroundwater Remediation
19:SAND/GRAVEL PACK rif a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft
_ Experimental Technology Subsidence Control fa ft
Geothermal(Closed Loop) DTracer >20.DRILLING.LOG'(attach additional sheets if recess )
Geothermal(Heating/Cooling.Conlin Return) Other(ex lain under#21 Remarks FROM TO DESCRIPTION(coia4 hardness,soiUrock a rain size,etc
ft ft
4.Date Well(s)Completed: Well ID# t S ft 3S ft
5 ell Locati n: ft 2� ft
ft. ft
Facili /Owner Name Facility ID#(if applicable) �S (� ft. ft.
it 060stj ►jt 7 (�1 F ft ft
P at Address,City,and Zip v" ft ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well 5el one tat/long is sufficient) Q'`} 22.Ce 'fi 'on:
Ari
N ^O V. �(� W1/rb4
6.Is(are)the well(s)rj Permanent or DTemporary Signs C fied Well Contractor D to
B3 signing th orm,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or QNo with ISA 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
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 if different(example-j3Q200'and 2Qa 100� construction to the following:
10.Static water level below top of casing: 1 `+ (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:
(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
pressure r ai
r pess 24c.For Water Supply&Iniection Wells: In addition to sending 13a.Yield(gpm) � Method of test: g the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Ckbrtk%q, Amount: DZ 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