GW1-2021-07831_Well Construction - GW1_20211102

Pnt Form,
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Informati n:
S 14-WATER ZONES l`: ..::,;.;r :7
FROM TO DESCRIPTION
Well Contractor Name ft ft.
3 ft ft
NC Well Contractor Certification Number 15:OUTER CASING:for•multi-cased wells OR LIlVER ifa- lickbley'.,=.`.
Morgan Well &Pump, Inc. FROM TI I DIAMETER THICKNESS MATERIAL
+1 ft. f[. 61/81 in' sd21 pvc
Company Name
16:`INNER CASING OR TUB7IV6 -eothe"rural dosed-too :' -
2.Well Construction Permit#: FROM4:1TO
DIAMETER THICKNESSMATERLILList all applicable well construction permits(r.e.UIC,County,State,Variance,etc.)- % in•
3.Well Use(check well use): ft in.
Water Supply Well: ....,.:,-,S . -.-....MATERIAL
PP Y f7lf, -
TO DIAMETER SLOTSIZE TITCKNESS MATERIAL
Agricultural nMunicipal/Public ftI Geothermal(Heating/Cooling Supply) J$esidential Water Supply(single) ft in.
Industrial/Commercial Residential Water Supply(shared)
18iGROUT...:
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft. bentonite poured
Monitoring Recovery ft. ft
Injection Well: ft ft.
roundwater Remediation
'19:SAND/GRAVELTAACK Cif a'licabl'e '
Aquifer Storage and Recovery OSalinity Banter FROM TO MATERIAL - • EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft ft
Experimental Technology [3 Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRILLING.LOG'(attacli'additidn'als7ieets ifnecessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To D RIPT ON(col r,har us,soil rock a rain size ere)
oft. Q ft V.
4.Date Weil(s)Completed: /d I� Well ID# O ft ft <V",
5a.Well Location: O
FacilityFacili y/�e Facility ID;#(ifapplicable) ft ft
ft. ft
Physical Address,City,and Zip ft ft 1(�� �` .1
_ z
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) * �O� `�� 22.Certification:
3`r d N�U laf W
6.Is(are)the well(s) ermanent or Temporary Signature of Certified 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: ©i Yes or o 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 ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For GeoprobelDPT 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 11 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: (ft.) 24a. For All Wells: Submit this;forum within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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:
(Le.auger,rotary,cable,direct push,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) /0 Method of test: air pressure 24c.For Water Supply&Iniection 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: 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 Revised 2-22-2016