GW1-2021-02554_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
ntractor Informatio
14.WATER ZONES.FROM TO DESCRIPTION -
Well ntra or Nam ft. ft
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for muld-cased.wells OR LINER if a livable
Morgan Well&Pump, Inc. FROM T DIAMETER i�clavEss MATERIAL
+1 ft fL 61/6/ in. sd21 pvc
Company Name I �
16:INNER CASING OR TIIBIIQG geothermal closed-loo :-
2.Well Construction Permit#: FROM To DIAMETER THICIavESs 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.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft is
Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) fL g, 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 DRecovery ft. ft
Injection Well: ft. ft
Aquifer Recharge [3 Groundwater Remediation
19:SAND/GRAVEL'PACK(if itp I plicable) '
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test Stormwater Drainage ft ft
Experimental Technology Subsidence Control IL ft
Geothermal(Closed Loop) Tracer 20.DRUAJNG.LOG:attach"additionalsheetsifnecess "
Geothermal(Heating/Cooling Return) Other(ex lain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock a in size,etc
o ft. S it. r
4.Date Well(s)Completed: A Well ID# ft. 20 ft
5a.Well Location: ft ft
fL Oft +J
Facility/Owner N Fa ility ID#(if applicable) ft ft.
ft. ft.
fL fL
P ysical ddress,City,and Zip 'y (r
s�,+ n '�.21 RRMARKC
County Av Parcel Identification No.(PIN) r
5b.Latitude and longitude in d ees/minutes/seconds or decimal degrees: (rl7vrli atlW Processingilo Unit
(if well field,one lat/long is sufficient 22. lion: P'CYIOn
a _N `'''1 . OW11 W 1
6.Is(are)the well(s)JIPermanent or [)Temporary S' o ertified Well Contractor Dat
135"signing this form,I hereby certify that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DI Yes or ®No with 15A NCAC 01C.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 Geopro e/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
constructs 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:230 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'mud 2@100) construction to the following:
10.Static water level below top of casing:�3D (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: 11� �1f 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
�! 1 , the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:(',�'►` inrle.) Amount: IQZ, 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