GW1-2021-04080_Well Construction - GW1_20210901

I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We Contra I for gtio
14-WATER ZONES i s
Well C(o�ntra or erne '�+�e• y FROM TO DESCRIPTION
lC� ej �0�1 ft ft.
t1 1 i
NC Well Contractor Certification Number 3 r;,C.e .....d
i" 15:.OUTER CASING for multi-cased
w'ells)OR LIl�R if a"'licalile=r.
Morgan Well & Pump, Inc. to ia.�it� nv�i ` .J'=-ittJjl FROM TO DrAnD:,TERp. THICENESS MATERLAL
lVJ +1 ft, ft. 61/8/ Vim' sd21 pvc
Company Name 0 "
16:INER N CASING OR TUBING eotheiin'al closed-Ido -
2.Well Construction Permit#: 52 FROM TO DIAMETER THICENESS MATERIAL
List all applicable well construction permits rz.e. UIC,County,State,Varannce,eta)- ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public fz ft in.
:]Geothermal Geothermal(Heating/Cooling Supply) ®IResidential Water Supply(single) ft ft. in.
I Industrial/Commercial Residential Watei•Supply(shared)
18.GROUT: ::
hn ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. bentonite poured
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
!Aquifer RechargeGroundwater Remediation
.19.'SAND/GRAVEL'PACK if ii .livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test [3Stomlwater Drainage ft fL
J Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 20.DRDS3IVG..LOG'(attacli'additidnal'shietsifneceis"
FROM TO DESC IPTI Q N(color,hardness,soil rock type, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
�7 — ft. A ft. 11
4.Date Well(s)Completed: ` Well ID# 5 ft !�45 ft.
5a.Well Location: ft "30 ro
dc-
Facility/Ow N e Facility ID#(if applicable) ft ftJ.
�r� �� ft ft.
ysical Address,City,and Zip�`� ft ft.
21.iREMARKS::_. t::•.,. . .;' ..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one
�lat/lo�ng is sufficient) Jy 22.4tion:5s5W�I•[� N '� a �1// W
6.Is(are)the well(s) Permanent or OTemporary Signatur Cert' 'ed Wel ontractor D e
By si. g this rm,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or-®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair•,fill out known well construction information an'J 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 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,only 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: —Rye (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths'ifdierent(example-3 00'and 2Q1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casino 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: A construction to the following:
(i.e.auger,rotary,cable,direct push,et 6.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: g
the address(es) above, also submit ;one copy of this form within 30 days of
13b.Disinfection type:( Amount: 07, completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016