GW1-2021-02583_Well Construction - GW1_20210620

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
We Contractor Name FROM TO DESCRIPTION
�/ ��� x\ 6 ft G ft.
w1 � O v ` ft. ft
NC Well Contractor Certification Number \V V
\� .0 IS.OUTER CASING.for multi-cesseil wells'OR LINER if a' lieible
Morgan Well& Pump, Inc. PC° 'O� FROM TO DIAMETER TffiCk1VESS MATERIAL
�� �j +1 ft G ft. 61/8/ In' sd21 pvc
Company Name � � l
:016 INNER CASING OR TQBING` eothermal'etoied lod'
2.Well Construction Permit#: b FROM To DIAMETER TffiCKNESS MA't'aurer.
List all applicable well construction permits(Le.U1C,Cowtty,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
a-. ..
Water Supply Well: FROMCENTO DIAMETER SLOT srZE THiCKNFSS MATERIAL
Agricultural [3Municipal/Public ft ft in.
_Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft
Industrial/Commercial DResidential Water Supply(shared)
>:18.GROUT.`
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft PO ft bentonite poured
Monitoring QRecovery ft fL
Injection Well: ft ft
_Aquifer Recharge )Groundwater Remediation
a
19.SAND/GRAVEL'PACK if a 'licabl'e
Aquifer Storage and Recovery OSaLinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
_Aquifer Test 0 Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer A DRU!JNG..LOG'ittacti-sdditlonal stieets
Geothermal(Heatin .Conlin Return) J Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soil/rock n stze etc.)
U` ft ft t
4.Date Well(s)Completed:(g-l ?'k Well ID# 'LC, G ft r04r— •0'r
5a.Well Location: �v ft (j ft G �
VO4, of / iJ It. 6d ft {Z�C,r�r`` \ ra.
Facility/Owner Name, Facility ID#(ifapplicable),/ �jC3ft U ft.
� ye I -roe"'t- �C�o6l � ✓��e_ ft ft
Physical Address,City,and Zip ^/ ft ft
L(.,CO(I C�_12 21:RF.MARKR:,.:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well one Ui 7 5 tffi Cf N 1 L�� ��C� W 22rC:� lion:IJVI/ — 1 S Z6Z�
6.Is(are)the well(s)lmPermanent or Temporary Si ture of Certified Well Contracto ate
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or No with ISA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information an explain the nature ofthe copy ofihis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform. 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �O (fi) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q1001 construction to the following:
10.Static water level below top of casing: qO (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
j� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �a l construction to the following:
(Le.auger,rotary,cable,directpush,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: C'Y4��-� Amount: C��GU 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