GW1-2021-07842_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: !
1.Nntractor Information:
n .
14..WATER ZONES
FROM TO m DESCR1PT10N
Well Contractor Name
35 /� ft ft
ft ft.
NC Well Contractor Certification Number 15;OUTER CASING.(fdr multi-cased'wills) LINER if a livable .t
Morgan Well &Pump, Inc. / FROM TO DIAMETER THICKNESS MATERIAL
I �e +1 ft ft. 61/81 ! In. sdt21 pvc
Company Name /1KW 1 ,�0 I INNER CASING OR TUBING'�eotheiu al e16'sed loo r
2.Well Construction Permit#: y1i V1 f�f�tTo
DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.VIC,Countv,State,Ymdance,etc.) ft in.
3.Well Use(check well use): ft �•
Water Supply Well: :H: n...... ...
PP Y FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft ft. in.
i Geothermal(Heating/Cooling Supply) INResidential Water Supply(single) ft ft
I lndustrial/Commercial E)Residential Water Supply(shared)
;Iriation FROM TO MATERIAL EMPL.ACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft bentonite poured
Monitoring QRecovery ft. ft.
Injection Well: ft ft
__I Aquifer Recharge rJ1 Groundwater Remediation L9.SAND/GRAVEL-PACK if a :.i ld like ;. ....'. .., .
Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
_Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DREU NG.T G(atti6-idditidu'sl sL'eetsif iie6eis- `)'i: - €
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To co o D CRIPTION( r,hardness,soil/rock a rain size,etc
ft V ft ,('
4.Date Well(s)Completed: �3v ` Well ID# v
5a.Well Location:
ft ft
Facility/Owner Name Facility ID#(if applicable) / ft ft
� 1Ve ft ft
Phys'a1 Address,City,and Zip t '
ft. fL
2r:REMARxs°-:.::::;:.::: ON
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
rtwell fie d,o la is sufficient) 4 r� �
�S � 6�- N �SY7.s9 22.Certification: �J' ,�..
W SPPIe.,f ?oZ
6.Is(are)the well(s) ermanent 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: OYes or J+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 ififormation 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 GWneeded. 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 dierent(example-3Q2000''and 2Qa 100) 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 Ceinter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 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: 4!P�E / construction to the following:
(i.e.auger,rotary,cable,direct push,ete.)��
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) `-a 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: rV.+/1{r Amount: oa, completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Envirownental Quality-Division of Water Resources Revised 2-22-2016