GW1-2021-07840_Well Construction - GW1_20211102

�Pr nt Form,_
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1
1.Well Contractor Infor ation:
14,.WATER ZONES- .- :f-'.':..:•;{,: .:' ..,. .
FROM TO DESCR1PT10N
WellCContractorName UC ft
J� ft ft
NC Well Contractor Certification Number
15:OUTER CASING,(idi•multi-cased wells)OR LIlVER " Uciible .l.'.'*:,:
Morgan Well & Pump, Inc. FROM TO DIAMETER THICKNEif a 'SS I MATERIAL
+l ft L� ft: 6118/ in. sd21 pvc
Company Name V
L 16:`INNER CASING OR TUBING eothermal closed-lod r
2.Well Construction Permit#: ll(+++ 11 l FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC,County,State,Variance,etc) ft ft. in.
3.Well Use(check well use): ft ft in.
FROM TO DIAMETER -
Water Supply Well: 17:SCREEN',:='. .<.:::_. . ..:.. :.,._..:....: .... ..�.. .::.:,.:-..•::-:;,_.>. .,�.;.. ..�', •:
pp y SLOT SrZE THICKNESS MATERIAL
:')Agricultural
QMunicipaVPublic fc ft in.
]Geothermal(Heating/Cooling Supply) &esidential Water Supply(single) ft ft
Industrial/Commercial DResidential Water Supply(shared) GROUT
1 hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring Recovery ft ft
Injection Well:
ft. ft.
_.1 Aquifer Recharge [)Groundwater Remediation
!:19:SAND/GRAVEL PACK rf ii 'licilile - -
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
i Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer . 20.DRUIJNG.LOG'(atticli-sdditionalsti'eetsifiiecess
J Geothermal(Heating/Cooling Return) _Other(explain under#21 Remarks) FROM To D RIPTI N(color,nary ess,soil/rock ty a gin size,etc
Z 6 ft �ft `/ z
4.Date Well(s)Completed: U` • Well ID# LD ft p ft. d'W�
5 Well Location
�:� d� p ft O ft
i/V ^ 'Y" / O ft 6 ft ✓�� ��1f►��i.
Facility/Owner Name .FaAcility ID#(if applicable) ft ft
Il , P� Gr` /—,d d��l/II�_ ft ft. y a a��j 'i'd
Physical Address,City and Zip
28`!
�C ft ft
-21:'RRMARKR'- �tj�b
County Parcel Identification No.(PIN) 71
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one laUloggQ sufficient) r�{�' 22•
N W
6.Is(are)the well(s)mrmanent or Temporary Simrature of Certffi ell Con ctor 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 or dNo 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 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 I 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: Ty SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 U (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2(Qa 100D 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 (i )` 24eW_;4=
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,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY YLLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 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:VJ r�'01'_ Amount: (d 0q_ 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