GW1-2021-07794_Well Construction - GW1_20211102

Print Form`"_
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I
1..Well
Contractor Information:/�
1 /1 1�� 1 y �V V I VVI r
14.WATER ZONES
RO TO DESCRIPTION
Well Contractor Name ^
3S� a, 1 ft ft _
ft ft �
NC Well Contractor Certification Number 15:OUTER CASING. multi-cased wells OR LINER(ifa:" livable•s,'r:
Morgan Well &Pump, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+1 ft ft 61/8/ in. sd21 pvc .
Company Name I INNER CASING OR TIIBING eotherma]clSsed-lode :
2.Well Construction Permit#: FROM KN
TO DIAMETER THICESS MATF.RTAT.
List all applicable well construction permits rLe.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in•
17.SCREEN..­'-
Water Supply Well: FROM TO DIAMETER OTIZE TH
SLSICKNESS MATERIAL
Agricultural [3MuaicipaUPublic ft It.
_Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft
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
Injection Well:
ft. ft.
_I Aquifer Recharge Groundwater Remediation
:'19: if SAND/GRAVEL-PACK a `livable
Aquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL FrrffLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRULIPIGI:OG'attadi'additiorial sheetsif necess
FROM TO DEsAPT ON(col r,kardness,sail/rock type,gmin size etc
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
ft ft. t'-
4.Date Well(s)Completed: U Well ID# / ft ft NL,N
ell—
Sa.Well Location: ft ft. JC f". .L
%Qar6GL j=a�r1S ft
Facility/Owner Name / (-Facility M#(if applicable) / ft v
Yzo ft. c 4
c�$6 VAS l�Dt n d/4COol�/ ft
Physical 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) 1 22. i ation•
35'- 39-7 g/- N .-8`� G��hoc. W er l�c�U r
IM
6 r�z
6.Is(are)the well(s)d.Permanent or OTemporary Signature f ied W ntractor Date
By signing i is form,I erebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or imAlo with 15.4 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}gneeded. 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 if different(example-3 cd 00'and 2Q100D construction to the following:
10.Static water level below top of casing: �G (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 fin.) 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: `" rj� construction to the following:
(i.e.auger,rotary,cable,directpush,etc.) �
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) U Method of test: air pressure 24c.For Water SuppIy&Iniection Wells: In addition to sending the form to
�, M the address(es) above, also submit" one copy of this form within 30 days of
13b.Disinfection type: (4/�✓�4"/ Amount:0Z� completion of well construction to!the county health department of the county
where constructed.
F
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016