GW1-2021-01969_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. a Contractor Infar anon: �
14.WATER ZONES
Well Contractor me p O .\ FROM TO DESCRIPTION
l �N Y � �5��9�J
� � P�O(� ft. ft.
NC Well Contractor Certification Number ( ec;
�n3`'A �Cj 15:OUTER-CASING formolti-cssedivells OR LINER ifa� llcible-�� _..
Morgan Well&Pump, Inc. {���, OV' FROM TO DIAMETER THICHIVESS MATERIAL
�(1s +1 ft ft 61/8/ in' I d21 pvc
Company Name /' ry
`/ a 16:1NNER CASING OR TIIBING `eoth"ermal closed-Ado
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft, ft in.
SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
J Agricultural OMunicipal/Public fit fit in.
-_ Geothermal(Heating/Cooling Supply) I&Residential Water Supply(single) ft. ft in.
J Industrial/Commercial Residential Water Supply(shared) 18.GROUT '
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUN
Non-Water Supply Well: 0 ft. 20 ft bentonite poured
Monitoring DRecovery ft. ft.
Injection Well:
fit. fit.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL-PACK Cif applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer t.26.DREU3NG.LOG:attach additional sheets if neces
Geothermal(Heatin .Conlin Return) J Other(ex lain under#21 Remarks) FROM To DESCRIPTION(rotor,hardness soil rock a to siu etc
U ft a ft. ,
4.Date Well(s)Completed: Well ID# ft. V ft. ���
5a.Well Location: ft. fit re
e
ft. fit
C Facility/OwnerJ Name `•//- Facility 1D#(if applicable) ft. fit
tO'O ✓`0�+, ` sG ac1/4- \ti{) Y' P-w- 1%-,is ft. ft.
Physical Address,City,and Zip ft. fit.
/ '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. er' cation:
5- 1630 N 1 N -$� 1 tigl?4 - W
6.Is(are)the well(s)APermanent or Temporary Signature of Certified Well tractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ®No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under t121 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 I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i SUBMITTAL.INSTRUCTIONS
9.Total well depth below land surface: t 6,5- (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a@200'and 2Q100D construction to the following:
10.Static water level below top of casing: (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 Infection 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: � � 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) ly Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
q �-1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 9«^"far Amount: / OZ_ 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