GW1-2021-00776_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD`(GW-1) For Internal Use Only: !
1. ontractor In 'm tion:
14..WATER ZONES
FROM TO DESCR1PT10N
Well Contrae rName j ft ft.
ft ft.
NC Well Contractor Certification Number
15:OUTER-CASING.(f&multi-cased wells)OR 11NER(if-a livable'
Morgan Well&Pump, Inc. FROM I TO DIAMETER I TEICKNESS MATERIAL
+1 ft. ft' 6 1/8/ r in' sdr21 pvc
Company Name
16:INNER CASING OR TUBING"-eotherntal clb-sed-ltid
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc), ft ft. in.
3.Well Use(check well use): ft. ft in.
17.-SCREEN'..:". .:;.
Water Supply Well: FROM I TO DIAMETER SLOT STZE TRTCKNESS MATERIAL
Agricultural QMunicipal/Public ft ft in.
i Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft ft.
i Industrial/Commercial Residential Water Supply(shared) ::,_ :.•= ==:- "
.:I&GROUT. -
E IrTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft, bentonite poured
Monitoring 1311ecovery ft ft.
Injection Well: ft ft.
_I Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL-P,&CK if a 'lld ire "
'Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test [3Stormwater Drainage ft ft.
Experimental Technology (Subsidence Control ft ft
Geothermal(Closed Loop) [3Tracer :20.DRILLING.LOG(attach'additiorisl'sh'eetsifnecess' `)',: ' '`'::: €
FROM I TO DESC rPT ON(color,hardness,soil/rock type,grain'size,etc.)
Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) 6 ft Im ft.
` d
4.Date Well(s)Completed:) ` Well ID# ft. a;b ft.
ft ft
5a.Well Location:
�� j
ft
Facility/Owner Name Fa lity lD#(if applicable)
ft.
ft. ft. l
ft ft.
�Ph sical Address,City,and Zip
j�I".�,,[[4 �
!� (]i t�
County Parcel Identification No.(PDT) n .•r=;� i r, +.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iiffwe�ll field,one lat/long is sufficient) 22.Cer. tion'
N "�0LJ i�j 3 W y`�L
4��L
6.Is(are)the well(s)JOPermanent or Temporary
Signature 'rt ed Well Contractor Date
By sig e t arm,1 hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: ©I Yes or WNo with N 01C.0100 or 15A NCAC 02C.0200 Well Construction Standwds and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this and 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,only 1 GW-1 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: i ✓ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@I00D construction to the following:
10.Static water level below top of casing: CJ.t 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: O Y LI construction to the following:
(i.e.auger,rotary,cable,direct push etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPP Y%WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I.
13a.Yield(gpm) 0 VZ Method of test: air pressure 24c.For Water Supply&IniectionWells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection ty�e:1byl he Amount: completion of well construction to the county health department of the county
where constructed. k
Revised 2-22-2016
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources !