GW1-2021-02000_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD For Internal Use Only:
I.,AVfll Con_tractor Information:
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Well Contractor Name Gl FROM TO DESCR1PT10N
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NC Well Contractor Certification Number .��\ a�CJ 15FOUTER CASING for multi cased'wells OR LIlQER tf a' lidible''
Morgan Well&Pump, Inc. \fit J��s Q� FROM TO DIAMETER THICKNESS MAT-ERrAL
+1 ft fL 61/6/ tn' sdr11 pvc
Company Name 16:INNER CASING OR TUBING`-eotheirnal.'clo3ed4du -
2.Well Construction Permit#: FROM To DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(I.e.NC,Comity,State,Variance,etc) ft ft in.
3.Well Use(check well use): ft ft in
17'SCREEN •` '...: _-
Water Supply Well: FROM TO DIAMETER SLOT SrZE I THICKNESS I MATERIAL
Agricultural QMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) 18:GROUT -
.
Irrigation FROM TO MATERIAL FNVL4CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
Monitoring QRecovery ft ft
Injection Well: ft ft
__!Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL'PACK ,Ucablb
Aquifer Storage and Recovery OSalinity Barrier FROM I To MATERIAL. I EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft
Experimental Technology Subsidence Control fL ft
Geothermal(Closed Loop) 1I Tracer t 2d.DRnS.JNG LOG'attarli-additi'6usl stieets tf necess _-
FROM TO DIESCRIPTION(color,hardness,soft/rock type,grain sim,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks ft , ft q
4.Date Well(s)Completed:l7 Iq r'71 Well ID# 75-ft- Ion Y` I*—
5 ell Location: '7S ft ft , _
ft ft
Facility/Ownerr Name Facility ID#(iff applicable) ft. R
o)`-V 16i k- r \ 1��e_CJ(� G►�,ca►ti % ft
ft
Physical Address,City,and Zip ft _
County l Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ll field,onglat/long is sufficient) 2 .C tification: v
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6.Is(are)the well(s) Permanent or MTemporary Signature of C56tified Well Contractor Date
�/t By signing this form,I hereby cerkfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or MNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and than a
ff this is a repair,fill out known well construction information an explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thfsform. 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: I L�l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: y / (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 aC200'anndd 2@1001 construction to the following:
10.Static water level below top of casing: L/ �/ (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
�(J above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 6 - construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY 'EE LS 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: V 1(Gnc e:/- Amount: q G1- completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016