GW1-2021-04720_Well Construction - GW1_20210527

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Print Form=;_
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor N m
ft ft
ft ft
NC Well Contractor Certification Number
15:OUTER CASING:(for multi-cased.wells OR'LINER. if a livable t Morgan Well & Pump, Inc. FROM TO DIAMETER TffiCKNESS MATERIAL
+1 ft ft 61/8/ 1°' sd21 Pvc
Company Name
�� (/ (�/n f7 IC INNER CASING OR TURING--eotherm'al d6i&14dd
2.Well Construction Permit#: (1,G•f11�` FROM TO DIAMETER 1HICICNEss MATERIAL
List all applicable well construction permits ri.e. UIC,County,State, Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft in.
I 17:SCREEN
Water Su ,. ,.
PP Y Well: FROM TO DIAMETER SLOT SIZE THiCICNESS MATERIAL
Agricultural OMunicipal/Public ft ft in.
_ Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
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i Industrial/Commercial Residential Water Supply(shared) AS.GROUT
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 Recharge []Groundwater Remediation
<19:SAND/GRAVEL'PACK d a 'liralile
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 x 26.DRILLING.LOG'(ittach'additional ii ieeti if necessa")
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIP ION(color,hardness,soiUrock a rain size,etc.
11 b ft (S ft YC' l 1't'
4.Date Well(s)Completed: J-� Well ID# iS ft ft. bYc)Wh A rt—
5a. ell Location: `SO ft. ft �t3W YDL�
V l ?✓ ft p f ue' Yt�1 it
t.
f
Facility/Owner Name Facility (ifapplicable)
_ /�ty —, SL �� t � �
Pff ft.
� � ft
� t.
ii.
l Address,City,and Zip
Ci
':21c REMARKS
County Parcel Identification No.(PM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (��FC'SSIn`�U1Z1
(if well field,one lat/lon is sufficient) g� 36�� 2Wtiflcation: DIVVI6. 1,35• � 'f N — W6.Is(are)the well(s)oPermanent or Temporary Sed Well Contractor Da
rt
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or []No with ISA 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 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 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: ��� A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ii(different(example-3P200'mid 1@l00D 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 casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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:
(i.e.auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
fr\
13a.Yield(gpm) L-,`'1 Method of test: air pressure 24c.For Water Supply&Injection 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: Amount: 7 c.Z completion of well construction to the county health department of the county
where constructed.
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Form GW-I Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016