GW1-2021-05918_Well Construction - GW1_20210901

�P;�int Form , --
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
T' La
ntractor Info ation:
G"'� 1 ,.9 ° p 14.WATER ZONES °.: -
.- `�,...9 t�• FROM TO DESCRU'T10N
Well n to ame `Aa'•--' nn++ ft. ft.
k,T1y t^I '�; A 2061 ft ft
NC Well Contractor Certification Number ��r t)1 i jt
!"Irr+.>,.(:r}i1���s -15i0UT$R CASING.frirmniti=cased well`s'OR�L-INER if a' licatile";�..
Morgan Well&Pump, Inc., - iit p t FROM TO DIAMETER THICKNESS MATERIAL
1r1�.Cl�3 M ` ft 61/8/ in, sd2l pvc
c
P y
Corn an Name 161"INPIER CASING OR.TUB
ING` e6theibialrl6sed-160
/ff�Il
2.Well Construction Permit#:� L• '�✓ � FROM To D
IAMETER MATERIAL
List all applicable well construction permits(.e. ,County,State,Variance,etc.) ft ft.
ft ft
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. ft in.
-JJ Geothermal(Heating/Cooling Supply) Er Residential Water Supply(single) ft ft. in.
I Industrial/Commercial Residential Water Supply(shared) - -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
.:.-')Monitoring Recovery ft ft
Injection Well: ft ft.
!Aquifer RechargeGroundwater Remediation
M SANDIGRAVMPACK Q1f
Aquifer Storage and Recovery 13SaLinity Barrier FROM TO MATERIAL EiLACEMENT METHOD
)Aquifer Test E3Stormwater Drainage ft ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 211.DRILLIlVG.LOG'(itti'6'sdditiona1'Eieti-if¢eces's" )'a°.':::'"t: •'==:: :;',.:''.°
FROM TO DESCPIPTI N(color,hardness,soil/rock e, rain size,etc.
RGeothernial(Heating/Cooling Return) _'Other(explain under#21 Remarks) 0 ft 5 ft
e .,
4.Date Vell(s)Completed: Well ID# 1 ft ft .0 y r
5 .Well Location: f II
ft ft-
NA
���
Facility/OwnerNar Facility (ifapplicable) ft ft
1 ft ft
hysical Address City,and Z� ft fr.
-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one 1 Ulong is sufficient) / �/ 22.Cer• •on:
� Ll 4 N'° l) IIL3i(�s W
6.Is(are)the well(s)MPermanent or 13Temporary Signature rt/a Well Contractor Date
By signi this r I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or WNo with 15A NCAC 0100 or ISA NCAC 02C.0200 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 owiier.
repair under#t21 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
constructi 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: `"' (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-l3 e@200'and 2@I00D consttuction to the following:
10.Static water level below top of casing: (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY`VVELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 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 A' .Vvt, Amount: completion of well construction to;the county health department of the county
where constructed. {
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016