GW1-2021-02572_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ontractor Informa'o
14.WATER ZONES
FROM TO DESCRIPTION
Well cto N�
ft. ft.
ft. it.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Wells)' LINER if a licable)
Morgan Well& Pump, Inc. FROM To DIAMETER THICKNESS MATERIAL
Company Name ft- 61/8/ in. sd21 pvc
V
3 ^�� 16:INNER CASING OR TUBING eothermal closed ES
2.Well Construction Permit#: `0 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits rzTUIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft in.
— Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft in•
Industrial/Commercial Residential Water Supply(shared) 18.GROUT `
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft bentonite poured
Monitoring QRecovery fL ft.
Injection Well: ft. ft
Aquifer Recharge EJGroundwater Remediation
19:SAND/GRAVEL'PACK if sipplicatiM "
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 t.20.'DRU LING LOG attacti additidnel sheets if neceis
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCR TI N(col r,hardness,soil/rock a ram size,etc)
fL ft r
4.Date Well(s)Completed Well ED# fL ft 'Llmh di
ft ft. i<-
Xeq Jocation:
t
ft G-fti awn
Facility/Owner Name Facility ID#(if applicable) / ft ft r.
l
1 ��1 �iyi ke, c ft ft.
cal Address,Ci , Zip
2L`REAIARKS'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: WR Sedon
(if well field,one Iattlo�ng is sufficient) 22.Cer ation:
35�f1t N ' O� � �r ' , Z y �i
6.Is(are)the well(s)r]Permanent or Temporary Si ertified Well Contractor D
sign his form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or QNo with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0100 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 I 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-3 t@200'au12@1001 construction to the following:
10.Static water level below top of casing: 4D (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 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) V Method of test: air pressure 24c.For Water Supply&Iniection 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016