GW1-2021-07899_Well Construction - GW1_20211102

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
14:.WATER ZONES
FROM TO DESCRIPTION'
well Contractor Na a ft ft.
"A ft ft
NC Well Contractor Certification Number 15:OUTER,CASINGfE&multi cased wells)OR T_1NF R if'a livable'
Morgan Well &Pump, Inc. FROM O DIAMETER' THICKNESS MATERIAL
+1 ft 144 ft, 6118/ fin sd21 pvc
Company Name n 1G:'IIVNER CASING OR TIIBIIVG e'the'r'mal elo'seddod' r
2.Well Construction Permit#: ���0` 1� FROM TO DIAMETER in.
TffiCKNESS MATERIAL
List all applicable well construction per�mus .e771 =iv,Stale,Ymiance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
1Z:SCREEN',:•. r-_ ._ . .. . •;...
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural r.11 Municipal/Public ft ft in.
i Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
lndustrial/Com FROM
mercial Residential Water SuPP1Y(shared)
GROUT:: ;.,:•.;:;,..
E . TO MATERIAL
EMPL..4CEMENTMETH &.AMOUNT
& MOUNT
Iiri atiOnR
Non-Water Supply Well: 0 ft. 20 ft bentonite poured
Monitoring QRecovery M ft.
Injection Well: ft ft
_I Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL-PACK
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL: EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft
i Experimental TechnologySubsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRILLING.LOG'(atti' 2additionalslieetsifiiecess
FROM TO DESCRIPTION(color,hardness,soiVrock -e, in'st2e,etc.)
'Geothermal(Heating/Cooling Return) _�Other(explain under#21 Remazks) y� ft ft•
4.Date Well(s)Completed:—� Well ID# 1 ft. 3v fton
ft ft
5a.Well Location: V
ft ft I
� _ ! _'
Facility/Owner ame Facility ID#(if applicable) ft ft r,.i 4 r^t
'\ (� ft. ft A I
sical Address,City,and Zip �Q l ft ft \' J
V � .�/��• A DZ ` `21c'RFMARKR'" - ..__ t ,_:="7,..r i.<'.t@}.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer ratio
35. 5 l 23 N --�• 37/ W dD 2S z
6.Is(are)the well(s)&,Permanent or Temporary
Si, ertified ell Contractor Date
By signing is form,I hereby certify that the wells) was(were)constructed in accordance
7.Is this a repair to an existing well: [I Yes or. ®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 consb•uction iri/ormation 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 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: V (ft) 24a. For All Wells: Submit this form witbin 30 days of completion of well
For multiple wells list all depths if different(example-3 t@200'and 2@100� construction to the following:
10.Static water level below top of casing: �-Ao (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 oY L� - 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
13a.Yield(gpm) I Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
�j the address(es) above, also submit(one copy of this form within 30 days of
13b.Disinfection type:nyV%Ae - Amount `�pZ completion of well construction to t'I e 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