GW1-2021-07892_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.. tsaTM
n:
•14:WATER ZONES �-
FROM TO DESCRIPTION
Well Contra or ame
ft. ft.
NC Well Connector Certification Number
15:OIITER CASING:(foc multi•cased wells)OR L-IPIER if'a'- livable �j
Morgan Well &Pump, Inc. _ FROM 140, DIAMETER THICKNESS MATERIAL
+1 ft' ft' 61/8/ in' sd21 pvc
Company Name
353 I 16."INNER G OR.TUBING �eothermal�elb"sed-lod'
2.Well Construction Permit#: FROM " To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits 6.e.UIC,County,State,Ymiance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN._::. .<. :: .`,
::
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural QMuaicipal/Public ft. ft. F
in•
i Geothermal(Heating/Cooling Supply) J@Residential Water Supply(single) ft. ft. in.
I Industrial/Commercial Residential Water Supply(shared) iS:GROUT-
Ini ation FROM TO I`MATERIAL EMPLA CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• bentonite poured
'.Monitoring []Recovery ft. %
Injection Well: ft ft.
DI Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL-PACK d k 'licabFe "
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test []Stormwater Drainage ft ft
j Experimental Technology []Subsidence Control ft ft.
Geothermal(Closed Loop) []Tracer :20.'DRTLLING.I OG"(kttic3i'addiflon'al slieetsifnecess
FROM " TO DESCRIPTION(color,hardness,satl/rock e,grain'stze,etc.)
I Geothermal(Heating/Cooling RRettu�m)� ,I Other(explain under#21 Remarks) 6 ft ft
4.Date Weli(S)Completed:ryy L Well ID# / ft. ft.
e fL ft {a
Well Lgcation:
Facili weer N e Fac''ty ED1#(if applicable) ft ft
sical Address,City,and Zip ft ft
r•. '.
County Parcel Identification No.(PIN) �:ern„^..>ts .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t`
(if well field,one lat/long is sufficient) a 22.C cation:
Isis.0ts N -410-M!5 W La
6.Is(are)the well(s)J@Permanent or []Temporary
Siang rccl,02C.0100
ied Well Contractor Date
By i ninrm,1 hereby certify that the wells) was(were)constructed in accordance
7.Is this a repair to an existing well: ©'.Yes or NoNo wi n 15A or I5A NCAC OIC.0100 Well Canshuction 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#21 remarks section or on the back of this form. 23•Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
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 different(example-3Qa 200'and 2 a@1000 construction to the following:
10.Static water level below top of casing: (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 (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: r L� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL 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 one copy of this form within 30 days of 42
13b.Disinfection type( P_ Amount: completion of well construction to the county health department of the county
where constructed. {
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016