GW1-2021-00771_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
h
1.Well Contractor inform tion: i
•14:.WATER ZONES
FROM TO DESCRIPTION
Well ontractorName ft ft. ' '
S1ft u ft. I
NC Well Contractor Certification Number 15:OUTER-CASING.(foi mulfi=cased well§ OR L7NER(if'a livable
Morgan Well &Pump, Inc. FROM T DIAMETER TffiCI{�ESS MATERIAL
+1 ft. ft. 61181 i in,' sd121 pvc
Company Name 0,7)f n O�
3 '11 16:IPTNER CASING OR TDBING' eothermal elSsed-loo'
2.Well Construction Permit#: FROM - TO DIAMETER THICKNESS .` MATERIAL
List all applicable well construction permits rz.e.UIC,County,State,Variance,etc.)- ft ft i
in.
3.Well Use(check well use): ft ft.
17:SCREFN'.:,:. .:.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural jMunicipaUPublic ft ft �•
_i Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft. ft
i Industrial/Commercial DResidential Water Supply(shared)
g :;_-. a•=....;=
GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT .
Non-Water Supply Well: 0 ft. 20 ft' bentonite poured
Monitoring Recovery ft ft.
Injection Well: ft ft.
_I Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL•PACIC if a'licabre
'Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft
_!Experimental Technology [3Subsidence Control ft. ft
Geothermal(Closed Loop) 1ITracer 20.DRILLING.LOG'tattiiE-'dditidnallsli'eetsifiiHes's 'jYi:
FROM TO 'D CRIPTI N(color, ardness,soil/ro e, rain'size,etc.
i Geothermal(Heating/Cooling Return) l_Other(explain under#21 Remarks) ft d It. ,e ki
4.Date Well(s)Completed: J -�` Well ID / v ft' U ft' e
5 Well Location:
�v r ft ft
r
Facility/Own r Name — Facility M#(if applicable) ft. ft
ft. ft
ft ft
Physical Address,City,and Zip
REMARKS`- 7.
County Parcel Identification No.(PIN) u i ;t7PiiIUI:t t ar •:il =./i
5b.Latitude and longitude in degrees/minuttees'//seconddsyor decimal/degrees:
qufficient)
N^ �V� Gl ( ��Ll 22.Cer' on:
W
6.Is(are)the well(sPermanent or 13Temporary
Si, of Cert a ell Co actor Date
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: E Yes or &0 with ISA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#11 remarks section or on the back of this form. 23.Site diagram or additional well d eta!Is:
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 19 5, (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d8erent(example-3Q200'and 2@100� construction to the following:
10.Static water level below top of casing: (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
t above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r Q Y LI construction to the following:
(Le.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 SuppIy&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: rwl,t Amount: Z. 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