GW1-2021-00742_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well
Contractor Information:
fI�
14..WATER ZONES,.'.
FROM TO DESCWTiON
We Contractor Name ft ft
Y1a
ft ft
NC Well Contractor Certification Number
15:OIITER CASING,(foi multi-rased Fvells OR LIIVER(if'a"'livable
Morgan Well &Pump, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+t ft 176 ft. 1 61/8/ in' sdr21 pvc
Company Name
16:'INNER C 4SIlVG OR TIIBIlYG''ER mal closed ES r
2.Well Construction Permit#: �`�/V`I U /7 d FROM To DIAMETER THICIays MATERIAL
List all applicable well construction permits'(ie.LUC,County,State,Variance,etc.) ft ft
3.Well Use(check well use): ft ft. �•
Water Supply Well: 17:SCREEN',:,:.;<.:`::_. .' :,':.::r' ;.:::--... x.:.:. ...: • ,.
PP Y FROM TO DIAMETER ; SLOT SIZE THICKNESS MATERIAL
Agricultural r-liMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) Ep&esidential Water Supply(single) ft. ft in
I Industrial/Commercial Residential Water Supply(shared) 18iGRODT:
i Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft, bentonite poured
'•Monitoring QRecovery ft. ft.
Injection Well: ft ft
I Aquifer Recharge s Groundwater Remediation ..' ._. .• "..:;
,19:SAND/GRAVEL'PACK rf a`livable "
'Aquifer Storage and Recovery Salinity Barrier FROMIff"
TO MATERIAL =EWILACEMEINT• METHOD
_i Aquifer Test [3Stormwater Drainage 1 Experimental Technology Subsidence Control ft.
Geothermal(Closed Loop) 1ITraoer 20.DRILI ING.LOG'(attidi-additidiiiI sUetsjf
EGeothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) FROM To DESCRIPTIO (valor,hardness,soil/rack a grain size,etc.)
l — �\ ft ft. ,r
4.Date Well(s)Completed:1 � ?'� Well ID# v ft. ftJeAl
ft ft
Sa.Well Location:
De� / fL ft
Facility/O/w�ner Name �Facility ED#(iffsapplicable) l- ft ft
ft ft
Physical Address,City,and Zip ft.r1 LC)In.- 21:REMARKS
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.ftzq2:�
3S,y2533 N ^ 8�.05 R _/3 W /tiycicr+,b-v �Sz��
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify than the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or QNo with 15A NCAC 02C.0100 or 1SA VC4C'02C.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 ofthis record has been provided to the well owner.
repair under#2/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: % 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 ifdIerew(example-3@200'anndd 2@100D construction to the following:
10.Static water level below top of casing: J (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 Injection 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 1 "`Y L' construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY r ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Injection 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: «wI d Amount' O completion of well construction to the(county health department of the county
where constructed. G
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016