GW1-2021-02553_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. tractor of
14.WATER ZONES
Na FROM TO DESCRIPTION
�_ c 2_
ft. ft.
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi used wells OR LINER if a livable
Morgan Well & Pump, Inc. FROM To DIAMETER THICKNESS MATERLAL
+1 ft. fL 6 1/8/ in' sd,21 pvc
Company Name
16:INNER CASING OR TUBING `eottiermsl cl6s8d-lo6"
Z.Well Construction Permit#:
FROM TO D L
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fL in.
17.SCREEN .,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public fL fL in.
Geothermal(Heating/Cooling Supply) J§Residential 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 fL 20 ft. bentonite poured
Monitoring ORecovery ft. M
Injection Well:
ft. ft.
Aquifer Recharge [)Groundwater Remediation
19:SAND/GRAVEL"PACK applicable)
Aquifer Storage and Recovery [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft. ft.
Experimental Technology [)Subsidence Control ft. ft.
Geothermal(Closed Loop) [)Tracer 26.DRILLING LOG:attach additional sheets if recess
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(col r,ha ness,soillrock a rain size,etc.
n ft. fL
4.Date Well(s)Completed:__�V Well ID# o ft. �L5 ft
5a.Well Location: ft. -0
t�smn ft ft.
Faaccility/Owner�Name
,�j ,�/' Facility ID#(ifapplicable) ft ft.
\l `z,af.Ork s wILIi �W ft ft
P�6y+spi'c�all Address,City,and Zip fL ft
County Parcel Identification No.(PIN) Processing Unit
DWR Seoi,on
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification
39 N ��l,O/�2-3 W <:J r �12D 411M�lq
6.Is(are)the well(s)i*Permanent or [)Temporary raertified Well Contractor Dats form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or MNo with 15A NCAC 01C.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 ofthe copy ofrhis 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: 2,O_0 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,[jerent(example-33@2000'and 2@1001 construction to the following:
10.Static water level below top of casing: �.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 (i . 24b.For Injection 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
13a.Yield(gpm)�.-- Method of test: air pressure 24c.For Water Supply&Injection 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: 4R 6X completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016