GW1-2021-07846_Well Construction - GW1_20211102

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WELL"CONSTRUCTION RECORD (GW-1) For Internal Use Only:
Well Contractor Information: 4
c
J -)` V .14:.WATER ZONES r``-. •...r:.:-:..: .... ....... . _
FROM TO DESCRIPTION
Well Contractor Nam� w
Icy—) '�r(�1 ft ft �
ft ft
NC Well Contractor Certification Number — l
15:OIITF.R CASING(for multi•rased wells)OIl LIl\ER d a linable
Morgan Well &Pump, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+1 ft ft 61/8/ 1 in' I sd21 Pvc
Company Name ♦ �J v �J IN CKNESS _
w (J i NER.CASING OR TIIBING--eothermal d&sM Add' .
2.Well Construction Permit#: FROM TO DIAMETER Tffi - MATERIAL
List all applicable well construction permits fl.e.UIC,County,State,Variance,etc.) R• ft. in.
3.Well Use(check well use): ft ft in.
FROMCREE TO�. :.: DIAMETER
Water SupplyWell:
SLOT SIZE THICKNESS MATERIAL
Agricultural QMuaicipal/Public ft ft in. J
_1 Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft
I Industrial/Commercial Residential Water Supply(shared) 18.GROUT.
•.Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
J Monitoling DRecovery ft. ft.
Injection Well:
ft ft
-1 Aquifer Recharge E3Groundwater Remediation
19:SAND/GRAVEL-PACK if a licable
Aquifer Storage and Recovery C3Salinity Barrier FROM TO MATERIAL FrMPLACEMENT METHOD"
_ Aquifer Test E3Stormwater Drainage ft. ft
J Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer 20.'D G.LOG(attac]i'additianal sheets.if iiecess `)':' `: -':'• :.:.-:"'
Geothermal(Heating/Cooling Retum) n Other(explain under#21 Remarks) FROM To DESCRIPTI (color,hardness,soil/rock type, rain size,etc.)
ft ft rAJ
Q �
ry
4.Date Well(s)Completed: � ') Well ID# !v ft ft. `*.^ V.
5a.Well Location: n ./ �(" (� ft ft. Vr4.
nVl IN� L C 1K ft
Facility./Owner Name Facility ID#(if applicable) ft ftft. ft
74
1 �Y
Physics Address,Citj
and Zip Q�/' G'�a ft ft.
rne?
CountyParcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if�� ���d,on���is sufficient) J�. �M � w 22.Certification:
N W C)k-:::�Z�= OC-0-kf tt ZAJ
6.Is(are)the well(s)*rmanent or O-I Temporary 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: L11 Yes or MNo with 15A NCAC 02C.0100 or 15A NCAC 612C.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 ihe',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
is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: .f 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 different(example-3 c@2gq'and 2Qa 100) construction to the following:
10.Static water level below top of casing: •,][Q> (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 �n.) 24b.For Injection Wells: In,addition to sending the form to the address in 24a
yr 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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �+ Method of test air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit ohe:copy of this form within 30 days of
13b.Disinfection type:81r4t�v ^� Amount: 7 completion of well construction to the county health department of the county
where constricted. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016