GW1-2021-07833_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: _
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
1*2�1 Oft ft.
)� 1/A ft ft E
NC Well Contractor Certification Number 15:OUTER-CASING:ftic multi=rised wells OR LIIVER if'a lickble'
Morgan Well & Pump, Inc. FROM TO DIAMETER THICKNESSI MATERIAL
Company Name
c +1 ft- lO ft 61/8/ i in. sdr2l pvc
16:"INNER CASING OR TUBING-�eotherrnal clb's8d-ltid
2.Well Construction Permit#: f 5J V FROM To I DIAMETER I THICKNESS MATERIAL'
List all applicable well construction permits(:.e.UIC,Countv,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
1 17:SCREEN'.::.
Water Su
PP Y Well: FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural rilMunicipal/Public ft ft in.:
_I Geothermal(Heating/Cooling Supply) �esidential Water Supply(single) ft ft
Industrial/Commercial DResidential Water Supply(shared) 1S:GROUT.'
:Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&-AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
'.Monitoring 13Recovery ft. ft.
Injection Well:
ft
,J Aquifer Recharge s Groundwater Remediation 19.SAND/GRAVEL,PACK if a llca
t.
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_i Aquifer Test [3Stormwater Drainage ft ft
_i Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRILLIlVG.IOG'(att5ili`additidn'als7ieetcifiiecess 'j':; `= := 1
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DEECRIP1VON(wlar hardness,solYrock type,grain size,etc
ft. V ft
4.Date Well Is)Completed:/0'Z�2 Well ID# ft " ft'
SafzW�ell1LtLge t
ocation: 11� ^ � V ft f
Facility//Owwner Name C Facility ID#(if applicable)
ft ft.ft. ft
^1
Physical Address,City,and Zip 2 ~'
ft ft.
P.
l7�cS�bti 21:REMARKS :.. .. ..,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ell field one laUlong Hsufficient) 22.Cer p cation: V `
�.`.�ZS�
6.Is(are)the well(s)Wermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes orAl 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 and explain the nature of the copy of this record has been provided to the well owwer.
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 G4 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t � (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©200'and 2@1000 construction to the following:
i
i
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
I
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:
(i.e.auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY�W(E�LLS ONLY: 1636 Mail Service CelInter,Raleigh,NC 27699-1636
13a.Yield(gpm) �"' Method of test: air pressure 24c.For Water Sunuly&Iniection Wells: In addition to sending the form to
dd - —7 the address(es) above, also submit`one copy of this form within 30 days of
13b.Disinfection type: U�� A Amount: completion of well construction to Ithe 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