GW1-2021-00778_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
1.Well C ntractor Information:
14:.WATER ZONES
FROM TO DESCRIPTION
Well Contractor ame ft ft.
ft ft.
NC Well Contractor Certification Number
15:OUTER CASING.Wf multi=cased wells)OIt LIl�ER(if a 'ckble
Morgan Well &Pump, Inc. FROM TO DIAMETER TBICEaI'F.SS MATERIAL
+1 ft. ft. 61/81 in' sd21 pvc
Company Name
nnr^ 16:'INNER CASING OR TUBING eothei mal closed lod' :'
2.Well Construction Permit#: d`J G FROM To nIAMETER THICIavEss MATERIAL
List all applicable well construction permits 6.e.UIC,County,State,Variance,etc.) ft ft
ft. ft in. '6
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMuaicipal/Public ft ft in•
_i Geothermal(Heating/Cooling Supply) aResidential Water Supply(single) ft. ft. in.
i Industrial/Commercial Residential Water Supply(shared)
i ,.
:I GROUT.
hii atiOn FROM TO MATERIAL EMPI.VMMENT METHOD&.4LMOUNT
Non-Water Supply Well: p ft. Zp ft bentonite poured
Monitoring ORecovery ft. ft.
Injection Well: ft ft.
__I Aquifer Recharge Groundwater Remediation
J9.SAND/GRAVEL-PACK ff i licablle
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAI EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology [3Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer :20.-DRUXING.LOG'atticti`addittdiiatsh'eets,ifii cess- ':`::
FROM TO DESCRIPTION(color,hardness,sorl/rock type,grain'size,etc.)
EGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) O ft S ft. }—
4.Date Well(s)Completed: Well ID# 5. It. 3.S ft ►it '
54 ft. O ft p
Weil Location: ',`,
rl(� ft W ft ' -
obit. �.a►rnhalr
Facility/Owner Name Facility M#(if applicable) ft ft
1056 O`A 0 v r�s_C CZd Scx�sk�li C 224 1ft ft.
Ph sical Address,City,and Zip J
ft ft
to p N '21i'RFMARK.S I ,
County Parcel Identification No.(PIN) t
5b.Latitude and longitude in de.arees/miuutes/Seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: '
ls4s 1!�o02Z C 1
N "~ JAIL 5
w
6.Is(are)the well(s)if Permanent or QlTemporary
Sim a rtifie Well Contractor Date
S ignin h' orm,1 het-ebv certtfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or JoNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standm•ds and that a
Ifthis is a repair fill out known well construction information and explain the nature of the copy of this record has been provided to the'well owner.
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details'
8.For Geo robe/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: 4 0 (ft.) 24a. For All Wells: Submit-this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2Q100� construction to the following:
10.Static water level below top of casing: T O (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
ll.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: 1 "`Y LI 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) 2— Method of test: air pressure 24c.For Water Supply&IniectiJW.ells: In addition to sending the form to
1�,,. the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection typ �W� LV%`G Amount: completion of well construction to ttie county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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