GW1-2021-06630_Well Construction - GW1_20211007

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
LAVell Contractor reformation:
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WellContractorName FROM TO fDESCRIPTION u u
3S I � ft. t.
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egget�9 it. rr.
NC Well Contractor Certification Number L r]c c
Morgan Well & Pump, I N C act{a��� N``JP'y�'On Y FROM MUTE TO R CASING(for!m DIAME ER flti-(�id'*MiYLII
THICKNERSS a`licaATERIAL. .
��f�j�� t. is 6 1/8 1 '° Sdr21 PVC
Company Name/.�' YY/�/I�� L.e
J, '" „160NNER:C-ASING'ORT[1BING `eothermalc]o'sedaoo u.
2.Well Construction Permit#: FROM To DIAMETER TRR1cRavEss 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.
Water Supply Well:
PP y FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in, 1
I
❑Geothermal(Heating/Cooling Supply) 4WResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18'GROiTT
❑Irri ation. ❑Wells>100,000 GPD FROM TO yI MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- bentonite poured
❑Monitoring ❑Recovery ft. fL
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation _
-:19:�SAND/GRAVF.I:-P.ACg rf.a lics6le
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer 20d,DRILZIlVGLQG:iittacl eddttiouplsheets ifi@cess " r
FROM TO CRIP ON lor,har ness,soit(rock e,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt. ft. ' tr
4.Date Well(s)Completed:-7)l_�`A� Well ID# ft. ft fftw o.—
5a.Well Location- ft. 6 ft.
Facility/Owner Name `Ie Facility
ID'#(if applicable) I ft. ft.
Physical Address,City,id ZIP ft ft
—jo4 _ sZ1 RFMARKC­
County 1{4W-C—' Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(i�l field,One llraUlo�is sufficient) �� Q ��� 22. tifieation:
—U N t v W
6.Is(are)the well(s): IlPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisforn,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only I GW-1 i�needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:' ( 24.SUBMTTAL INSTRUCTIONS
-Z'7 d1%
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �d (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
]f water level is above casing,use"+"
6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: o (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rota'1t��
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Water Wells producing over 100;000 GPD100;000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) �U Method of test:
air pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: i�t� Cr Amount: CIO�
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018