GW1-2021-07897_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
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14:.WATER ZONES
FROM TO DESCRIPTION
We'VI Contractor Name
C ) ft ft I
a ft ft
NC Well Contractor Certification Number 15:OUTER CASING;(for multi-dosed wells Oft LINER(if livable
Morgan Well &Pump, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+1 f[, ft. 61/8/ ! tn' sdi21 pvc
16:'INNER CASING OR TUBING'k e
Company Name ?0610 othei utal closed rod' r
2.Well Construction Permit#: FROM TO DIAMETER TffiCKNmss MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
17.
Water Supply PP Y Well: FROMRF.F.TO DIAMETER:.....:;
SLOT STZE THICKNESS MATERIAL
Agticulttual r.'iMunicipa/Public ft ft
I Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft ft
Industrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft bentonite poured
Monitoring DRecovery
Injection Well:
ft. ft.
-!Aquifer Recharge QGroundwater Remediation
19:SAND/GRAVEL-PACK tf ii `iieible '
Aquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL FrlIPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology 13Subsidence Control ft ft
EGeothermal
Geothermal(Closed Loop) Tracer :20.bRILLING.IAG(attich'iddition'sl ihiets.if neces`s-d)':(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,n ness,soil/rocktype,grain size,etc.)
ft ft
4.Date Well(s)CompletedJ-70"' Well ID# � ft ft C JGir, oc
(/L
pit
5 .We Location: 137 ft LI
Vt ft ft
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Facility/&A Name (s Facility ID#(if applicable) ft ft
�`>✓ � �����Jr'tL� Sk- �I'aj1�Gl S ft ft
IL ft
Ph 'cal Address,City,and Zip
Zz
NO
County Parcel Identification No.(PIN) �I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if Well field, e��r
laUlOng i sufficient)
N —��,� W 22.Certification
:
6.Is(are)the well(s) Permanent or MTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cer4ify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consnuction Standa•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 421 remarks section or on the back of thisform.
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-I-I is needed. 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 ifdifferent(example-3Qa 200'and 2@1001 construction to the following:
10.Static water level below top of casing: f (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 in. 24b.For Iniection Wells: In addition to sending the form to the address in 24a
r .. ^ above, also submit one copy of this form within 30 days of completion.of well
12.Well construction method: it �/�� construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gP ) air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield m li Method of test: g
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: C /1� - Amount: /Z,?�9 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