GW1-2021-04464_Well Construction - GW1_20210901

WELT,CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well: ontractor Information
�'e,v - 14.WATER ZONES
Well Contract �! ^0�1 FROM TO DESCRIPTION
L ft ft-
ft. I
r��-r��:";`iiitCJ�11111 ft
NC Well Contractor Certification Number 1!P Js l n ;^;; t ` i 0n 15::OUTER CASING(for multi-cased wells)OR LM4ER if a"licatile
Morgan Well &Pump, Inc. [;�Jt�" FROM I T DIAMETER THICKNESS MATERIAL t
+1 ft. ft. 61/8/ in• sd21 pvc
Company Name 16.INNER CASING OR TUBING _eothei-mal 66sed-loo
2.Well Construction Permit#: nf'' 3 FROM TO DIAMETER TffiCIG`]ESS MATERIAL
List all applicable well construction permits f.e.UIC,Couniv,State, Pariance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
117.'SCREEN':
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural rIMutlicipal/Public ft ft. in.
:3 Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft
I hidustrial/Commercial [J Residential Water•Supply(shared)
18.GRODT: :.
—')Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
—71IMonitoring DRecovery ft. ft.
Injection Well: ft. ft.
-!Aquifer Recharge rJJ Groundwater Remediation
19:SAND/GRAVEL-PACK if a .licable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL MNeLACEMENT METHOD
i Aquifer Test [3 Stormwater Drainage ft. ft
J Experimental Technology Subsidence Control ft ft
Geothermal(Closed hoop) Tracer 20:'DRILLING..LOG'(attach2additionalsheets ifneri s" ')'•- >` :. :
FROM To DEseAPT[ N(color,hardness
i Geothermal(Heating/Cooling Retum) J Other(explain under#21 Remarks) soil/rock type rain size eta)
ft l ft CfA 1
4.Date Well(s)Completed: Well ID# IS ft. '-C� ft. 1
Sa.Well Location- ft ft
�/Yl 1��/•� ft. ft
Facility/ wner Name""✓✓ � Facility ID#(if applicable) 10 It. ft
Physical Address,City,and Zip ft. ft
an ..:. ..:..::.:..
:.21.RFMARKF::._--.:_� ' ..-�: ;. ._, :.. .. • .:�.., .,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
6�:�orL N s W
6.Is(are)the well(s)*Permanent or Temporary Siva �i.:Aform,
ified Well Contractor Da,
nin 1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes orlmNo with15A C 02C.0100 or 15A NCAC 01C.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 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
constrL , 1 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: !N"O (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 t@200'and 1Qa 100D construction to the following:
10.Static water level below top of casing: 40 (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: tir Y 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
(gp ) air pressure 24c.For Water Supply&Iniection Wells: In addition to sending 13a.Yield m �� Method of test: g the form to
A the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection 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