GW1-2021-06641_Well Construction - GW1_20211007

:
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ContrOctor Inform tion:
,14'WATER�ZONES r�: .
FROM TO 'DESCRIPTION h
We contractor Name ft. _) ft.
VIS
NC ell Contractor Certification NumberOUTER:CASING for,mnlh casedwe7Ls'OR'I$NER if a" luable)
Morgan Well & Pump, I N C FROM Ti)
DIFu�TER THICKNESS MATERIAL
ft. ft 61/8 ; in. sdr21 JPVC
Company Name
16INNER CASING:ORTDBING'(jeothermal:closed loo w>
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well constriction permits ri.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Su I Well: 1VSCREEN.-.'
PP y FROM TO DIAMETER i'SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public It. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:i6ROUT _ v
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SANI)IGRAVEI;PACIL if a'livable -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
i ..
❑Geothermal(Closed Loop) ❑Tracer %20DRII LINGT OG`atta�h'additiorial sheets if necess _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,softock type rain size,etc
d rt. ft.
4.Date Well(s)Completed: 1 Well ID# s' ft. a ft 4Ofr�� b
5 Well Location: U `('
L(yJ-r4 Am J ►'�tifa�'t/��� � �� ft. (�hft. ✓�
Facility/Owner Name Facility ID#(if applicable) ft. `v ft. �.
7
Physical Address,City,and Zip —y ft ft 7
171- ;,.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
��field,
,00ne lat/lloong is sufficient) �j 22.Certification: �J
N ^g� r-z5Oo `� W
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: Q 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: - 1 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Q100�
24a. For All Wells: Original form to Division of Water Resources ('DWR),
10.Static water level below top of casing: '+ (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Ro+`a't•]'��
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 producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) V Method of test:
air-pressure Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 6tr,-1uA4,0' Amount: d2
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018