GW1-2021-02528_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W Contractor Info ati n: �\/
��� 14.WATER ZONES
Well for Name FROM TO DESCRIPTION
,�� Q r6a'soq fL ft
NC Well Contractor Certification Number QrV�r$GiO� 15:OUTER CASING for multi eased wells OR LINER if a lieable "
Morgan Well &Pump, Inc. C�3� r1`�5 FROM r DIAMETER THICKNESS MATERIAL
+1 ft ft 6118/ in' I sdr21 pvc
Company Name r.
IC INNER CASING OR TUBING i eothermal clos2d-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]Agricultural [3Municipal/Public ft ft in.
_Geothermal(Heating/Cooling Supply) WResidential 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: 0 ft 20 ft bentonite poured
:')Monitoring Recovery ft ft
Injection Well:
ft ft
Aquifer Recharge 0J Groundwater Remediation
19:SAND/GRAVEL PACK Cif applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology D Subsidence Control ft ft
Geothermal(Closed Loop) Tracer "�2b.DPJ LLING.LOG attach"additional sheets if necess
Geothermal(H ooling Return) Other(explain under#21 Remarksl
FROM I To I DESCRIPTIo (color,hardness,soil/rock type,gmin size,etc
t� h 6 ft 1 1 Cam' ft A
4.Date Well(s)Completed: / ;L Well ID# ft c) fr )r
y ell L oc-a--�na ft C-ft DC
F/ LJ1715 ✓
ft �1 ft
Facility/Owner N Facility ID#(if applicable) ft ft
EM
PWicJ Address,City,and Zip ft ft
C-AhOJf a 21i REMARKS-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one lat/long is sufficient) ¢ Q� 22.Certification:
. SIU2 N
6.Is(are)the well(s)CjPermanent or Temporary ey'41g
of Certified Well Contractor Date this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or QNo 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#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-I 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: -1 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: TV (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 'n.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
` Y 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
air p 24c.For Water Supply&Inection Wells:.In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 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