GW1-2021-07799_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.WeA Contractor Information:
CY l v `— , "" IP'J y `yam� � 14.WATER ZONES;. l' .. •_.:. ' '' . ,
We1l2ConCtractorName �+ c� ^ ROM TO DESCRIPTION
:J J 13, � t l[l\f x �J ft ft.
IVU � ft ft ;•
NC Well Contractor Certification Number ¢ IO u�B$tCe, 15:OUTER,CASING'.(foc multi-rased wells)OR LINER if a" 'lickble•_".'"::..
Morgan Well &Pump, Inc. t"", ,3 o �p FROM 0 DIAMETER THICKNESS MATERIAL
C (,� ^u,l +1 ft .\ ft 61/81 in. sd21 pvc
Company Name ��V" I 1�y `v V
111 1 16:INNER CASING OR TIIBIIVG eothermal closed-loo
2.Well Construction Permit#:��\1 rt l� FROM To DIAMETER I THICKNESS IyMATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: FRo1,CIrTO DIAMETER SLOT SIZE THICKNESS rMATERIAL
Agricultural [)Municipal/Public ft ft in.
-_Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft. ft
i Industrial/Commercial [)Residential Water Supply(shared) 18.GROUT
- <r
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft 20 ft. bentonite poured
Monitoring ORecovery ft. ft.
Injection Well:
ft ft.
_.J Aquifer Recharge )Groundwater Remediation
19:SAND/GRAVEL'PACK ff a'hcablb
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_i Aquifer Test Q Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer 20.DRILLING.LOG'(atticb`additionAI stieets iiiieis` -)':i_ '
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM I To DESCRIPTION(color;hardness,soil/rock type,grain size,eta)
6 ft. ' o ft 05,(
4.Date Well(s)Completed: Well ID# ft. — ft. t&*� V% 1*1(
5a.Well Location. dsysk
ft
Facility/Owner Name Facility M#(if applicable) ft. ft
Of__% ft fL
Physical Address,City,and Zip ft ft
2L REEMARKs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if�ell fiiel-d',one lat/long is sufficient) p� 22. fication:
`�,S�Z�0 N .�D �. l- �3 W
6.Is(are)the well(s) rmanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or PgNo with 15A NCAC 02C.0100 or 15A NCAC!02C.0200 Well Construction Standm-ds and that a
If this is a repair,fill out known well construction iniformation 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 foam.
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-' tt
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 ifdifferent(example-3@200'm 2@100) construction to the following:
10.Static water level below top of casing: U (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 60n.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�27V
a above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: GC�/ 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
13a.Yield(gpm) 16 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:�n/wju.V— Amount: 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