GW1-2021-04075_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.W Contractorati—Ja/w '14.WATERZONES::-
FROM TO DESCRIPTION
Well Contrac of ame
� � 2�21 ft. ft.
✓r ft. ft
NC Well Contractor Certification Number -� n ,0:'c'''lt�Unit
15.OUTER CASING-(for multi cated'wells)OR'LINER(if a licatile= ":":z
t
Morgan Well & Pump, Inc. Irioll3'' , cam. ;on FROM T DIAMETER THICKNESS MATERIAL
�•.. "' +1 ft. / ( ,ft 6 1/8l in. sd21 pvc
Company Name
/f 16'INNER CAS GOR.TIIBING` e&heimsl.'closed-loo
2.Well Construction Permit#: /` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well.construction permits(.e.b7C,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft. ft in.
_SCREEN:,,>.::.. ". =. :.�.., .,.._.-.::. ;;.:.:-:•-s: :�-.:-rr:-_:..::-.. .__.:._ :.;.:. ";::r
Water Supply Well: FRO TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
_;Agricultural nMunicipal/Public ft ft
_j Geothermal(Heating/Cooling Supply) EResidential Water Supply(single)
lndustrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: 0 ft 20 fr' bentonite poured
Monitoring ORecovery ft. ft
Injection Well: ft ft
_ Aquifer Recharge Groundwater Remediation
19.SANDIGRAVELPACK if a licable
i
Aquifer Storage and Recovery $alinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:Aquifer Test !3 Stormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft ft.
-ilGeothermal(Closed Loop) [I Tracer (2b.DR1ILING.LOG'{attacli-sdditionalsheets=ifnecess
i Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM To ,DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. II-o, ft. o%-)in A tff°{�
4.Date Well(s)Completed: f Well ID# ft ft. k
5 Well Location: 4 ft. -0•ft. C
/�, � ft ft
cthty/Owner N e Facility IDJ(if applicable) ft ft
//P i'ysical Address,City,,and Zip ft ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)� (� ���� 22.Certification: q' N "� �LW
6.Is(are)the well(s) Permanent or Oj Temporary Signature of nifled We CoVA
Date
By signing this form,I hereby the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or *No with ISA NCAC 02C.0100 orCr02C.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 owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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,on -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: 3o-o (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q100� construction to the following:
10.Static water level below top of casing: T' J (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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: \y- A Lk construction to the following:
(i.e.auger,rotary,cable,direct push,et.)
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
f� the address(es) above, also submit j one copy of this form within 30 days of
13b.Disinfection typd's�I10Y_1 l"P✓ Amount:�EiQ� 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 1 Revised 2-22-2016
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