GW1-2021-00716_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
f
1.Well Contractor Informatio :
14.WATER ZONES
FROM T DESCRIPTION c
Well ntracior2NamCe I� ft ft-
ft. ft M
NC Well Connector Certification Number 15;OUTER CASINGAdi•multi-cased wells Oft LIIQER if a- ridable' ".
Morgan Well &Pump, Inc. FROM 'ro DIAMETER THICKNESS MATERIAL
+1 ft ft 6118/ ' in. sd21 pvc
Company Name :i
�1 1� 16:'INIQER CASDVG OR TUBING"•cothermalclo'sed-lode .
2.Well Construction Permit#: ` ` FROM To DIAMETER THICHNEss .` MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft m.
in.
3.Well Use(check well use): ft ft
17:SCREEN',
Water Supply Well: FROM . TO DIAMETER SLOT SIZE TRiCKNFSS MATERIAL
Agricultural QMunicipaUPublic ft ft. in.
1 Geothermal(Heating/Cooling Supply) J&esidential Water Supply(single) ft ft
i Industrial/Commercial DResidential Water Supply(shared) ;!18:GROIIT: .:; _ _.:=-:.� ,.�_.�..:;.._:: `;:• ';.. ,�::':.' ..: ;.
I Irrigation FROM TO MATERL4L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring Recovery ft. ft.
Injection Well: ft ft.
1 Aquifer Recharge Groundwater Remediatioa
•:19:SAND/GRAVEL'PACK(if a'licalile
v'Aquifer Storage and Recovery USallnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
_ i Subsidence Control ft ft
i Experimental Technology
i Geothermal(Closed Loop) OTracer 20.'DRMI ING.LOG'(attiiYiddition'al sfie6idifrieceis' :�,.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DEse IPT ON coi r,Hardness soil/rock a grain sve eta
` ft ft
4.Date Well(s)Completed: _tiM•ti1 Well ID# / ft ft. "_�r�•
5a.Well L\o_cation: U ft ft- Ckn J p n—` I
Facility/Owner Name Facility ID#(if applicable) tzcxf vfr IN . 4�!—
6105 OBco014-1;n.,— r thx \o\�� ft f r._4;-r �\tt . .
ft ft i
Physical Address,City,and Zip
11 �sy r s y asa _
County Parcel Identification No.(PIN) tl'.• n=t i .1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
..•..::.n a.rra:r%:`.•``,r(-c;C,it i5 l)i�i
(if well field,one llat/long is sufficient) Q1 Q 22. . cation:
9�J-X37o N ��U NO W
6.Is(are)the well(s)oPermanent or Temporary
Signa of Certified Well Contra to
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: DYes or ©No with 15A NCAC 02C.0100 or 15A NCACO2C.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 ofihis record has been provided to the well owner.
repair under#2I 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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / O (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: �U (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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: Y L� construction to the following:
(ie.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) 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
13b.Disinfection type: Amount I 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