GW1-2021-02529_Well Construction - GW1_20210620

11. Paint FormLi
WELL CONSTRUCTION RECORD (G`V� � For Internal Use Only:
1.Well a ontr ct �\ on: �3
V � 14.WAT'ER ZONES.:.: _
Well n ffame ! FROM TO DESCRIPTION
e�y�� ft ft
\ �O�
Q� 6G�• ft ft
NC) ell Contractor Certification Number
311? 1Q. 15.OUTER CASING.formalti=cased wells OIt'LIIVER if a' livable:f 't -
Morgan Well& Pump, Inc. �f�• p� FROM To DIAMETER THICKNESS MATERIAL
c +1 ft ft 61/8/ 1° sdr2l pvc
Company Name _
n� 16:"INNER CASING OR TQBING` `eothermal:closed4od� :'
2.Well Construction Permit#: 'r J FROM TO DIAMETER THICKNESS MATERLL
List all applicable well construction permits(i.e.L7C,County,State,Variance,etc.) M ft In.
3.Well Use(check well use): ft ft in.
Water Supply Well: '171'SCREEN .•�.::.; •.>: ,.:...,..,_..�.:-.�:.:~;:. >,-..�: �;:.:_-:_'. ;r:.;:;.�..'.;:�.�-..::
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_;Agricultural QMunicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft In,
Industrial/Commercial DResidential Water Supply(shared) _
`18:GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring DRecovery ft. ft.
Injection Well:
ft ft
Aquifer Recharge M11 Groundwater Remediation
19.SAND/GRAVEL`PACK if a "licabl`e
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMEIV'r METHOD
Aquifer Test !3 Stormwater Drainage ft. ft
Experimental Technology EJ Subsidence Control ft ft
Geothermal(Closed Loop) _)Tracer 12b.DRMLENG.LOG a'tta6'additional slieets:ff¢aces "
To DESCRIPTION(color,Hardness,soil/rock
(Heating/CoolingRetum) Other(explain under#21 Remarks) FROM a grain size,eta
0 ft —VC ft
4.Date Well(s)Completed: Well ID# ,0 ft 35-0 ft
5a a Loca' n: Aw ft ft.
� yyl ffC/` ft ft
q(rowper ►►► ID#(if applicable) ft ft ft ft
P sic 1 Address,City,and Zip fL fr'
21:'RRMARKS - - - - -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwe1el
ll field,
one
lat/long is sufficient) Q 22.Ce cation:
: SSO A no N _0© ' � W
6.Is(are)the well(s)nPermanent or OTemporary i o ell' ed Well Contractor a
B s'nin his form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or NNo wit 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Wen 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 I 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: q6b (ft-) 24a. For All Wells: Submit this fort within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q2C00'and 2@1000 construction to the following:
10.Static water level below top of casing: (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: cl f 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
air pressure 24c.For Water Supvly&Injection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: g
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection typeww Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016