GW1-2021-02359_Well Construction - GW1_20210723

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I
1 -Eontrac i! ormation:
G••34•''�.+'•Nl, la..wATER zoNEs,
FROM TO DESCRIPTION
Well Co c rName
l ft. ft
1"-2 1,1 Cj �a �OZ� ft ft
NC Well Contractor Certification Number J b+ U�1� 15::OUTER CASING(for multi-cased we1Ls)OR LINER if a"'livable-;.
Morgan Well & Pump, Inc. glll� FROM T DIAMETER THICRYESS MATERIAL
+1 ft. qij ft. 6 1/8/ in. sd21 pvc
Company Name /, D 16:INNER CA OR TQBING _eottiel al closed4dd _
WA FROM TO DIAMETER TMCKNESS MATERIAL
2.Well Construction Permit#: � 1
List all applicable well construction permits(.e.WC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): fL ft in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural Agricultural Muaicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
i
i lndustrial/Commercial Residential Wat&Supply(shared) 18.GROUT: ::'. ..:
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft bentonite poured
Monitoring Recovery ft. fL
Injection Well: ft ft
-_i Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL'PACK if a 'livable
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) OTracer 20:'DRILLING.LOG-(ittacti+additidnal'stieets if iieces"s"")',:-
FROM TO ESCRIPTION(color,hardness,soillrock type, rain size,etc)
Geothermal(Heating/Coolfin�g R/ettun) _'Other(explain under#21 Remarks) � ft ft
4.Date Well(s)Completed- / IJ F q�41 Well ID# ft. ft
s TT ll tio ft
k�'J,
Loca w,Facility/Owner Name Facility ID#(if applicable) / ft. ft ft fL
,�®��P ysical Address,City,and Zip ft. ft., ¢.A
21:I2EMARKS':'t{:•.;' .. : ;. .... .. - ....: .,,�.. _
rrU�,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
lfield,
one lat/long is sufficient) 22.Cer' cation:
� f 3 1 N �:3q4! W 6
6.Is(are)the well(s)0 Permanent or Temporary M175
Certified Well Contractor to
his form,I hereby ceii�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or []No AC 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 ow•»er.
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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q100D construction to the following:
M 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 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: construction to the following:
(i.e.auger,rotary,cable,duect 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) 7— Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
/�+�,��e the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection typAl164'twL Amount: � — completion of well construction to fthe 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