GW1-2021-02357_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. ell Conti TMA tin:
(.�'
N 14.WATER-ZONES
Cootri-
ft.FROM TO DESCRIPTION
+�`` ft
NC Well Contractor Certification Number ,1
J�� UlAlt -15i OUTER CASING.(for multi=cased'wells)'OR LINER(if a" bcable"
Morgan Well & Pump, Inc. �,o�ess�n9 FROM O DLIMETER TffiCKNFSS MATERIAL
+1 ft ft 61/8/ In. sdf21 pvc
Company Name 1 CC IN Rt
]"� D16:IN1VER GAS G ORTOBING' `eothermil'tilosc3=lode
2.Well Construction Perm n/ f./it#: Ci ` FROM ToI DIAMETER T>U0WEss MATERIAL -
List all applicable well construction permits(.e.VIC,County,State,Variance,etc.) ft ft in•
3.Well Use(check well use): ft ft
! 17;'.SCREEN
Water Su
PP Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultu al QMunicipal/Public ft ft
Geothermal(Heating/Cooling Supply) wResideatial Water Supply(single) ft ft in•
Industrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft PO ft. bentonite poured
'Monitoring ORecovery
Injection Well: ft ft
_-I Aquifer Recharge EJJ Oroundwater Remediation
.19.SAND/GRAVEL'PACK if a licabl`e
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_i Aquifer Test Stormwater Drainage ft ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) [3Tracer 92b.DRLLLING..LOG'fittacti'addittonal iS&d:ifnecess );'a:.: =. :`
Geothermal(HeatinglCooling Return Other(explain under#21 Remarks) FROM TO DESCRI TIO (color,hardness,soil/rock a rain size,etc
C> ft VO ftKrd / 0Y--
4.Date Well(s)Completed: Well ID#
iMIUI ocation:
Facilityy/�werN Fac tyID#(dapplicable)) ft ft.
S� ��►1 `1 WJ rely h, 27�I`l j,� ft ft.
Physical Address,City,and Zip ��—= ft ft
n -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) Q `� J 2 e • cation:
N _ D0 a W
6.Is(are)the well(s)mPermanent or OTemporary Sl a of ertified Well Contractor a
By signin is form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or NNo with 15A 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 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 d;agram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may se 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 constmctio -details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z07t) (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 00'and 2@100) 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
II.Borehole diameter: 6 in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
f �A_ above, also submit one copy of this lform within 30 days of completion of well
12.Well construction method: 71AI r anA 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) Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type&,13 In in, Amount: completion of well construction to the county health department of the county
J where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016