GW1-2021-02363_Well Construction - GW1_20210723

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.WeltContrac. Information:
sFROM TO ...:.....-...: - . .
14.WATERZONES DESCRIPT
Well C tractor Name � ION
ft ft
ft ft
NC Well Contractor Certification Number
J d OUTER CASING(for'multi=cased wells OR'LIlVER if"a" licatile`>
Morgan Well & Pump, Inc. nro"'S (3 FROM TO DIAMETER THICKNESS MATERIAL
�� +1 ft ft 61/81 in. sdr21 live
Company Name /J ��^ ib
1�iJr "cLdl lbi'INNER G G OR:TUBING' edthermal:desed=lod
2.Well Construction Permit#: FROM To DIAMETER TffiCKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft in.
17:'.SCREEN
Water Supply Well: FROM TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL
.J Agridultural E]Municipal/Public ft, ft in,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
J
i Industrial/Commercial E311esidential Water Supply(shared)
:18.GROUT. -':::...:,:r...: . ...
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft* bentonite poured
Monitoring QRecovery ft. ft.
Injection Well: ft ft.
I Aquifer Recharge M Groundwater Remediation
"'Aquifer Storage and Recovery MI Salinity Barrier FROM To MATERIAL EMMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft ft.
Experimental Technology O_i Subsidence Control ft I ft.
Geothermal(Closed Loop) E3Tracer 9 2b.DRULTa G.LOG'fitticti-`additional sheets:if neceisa
Geothermal(Heating/.Cooling Return) -J Other(explain under#21 Remarks) FR�OlM TO DESCRIPTION(color,hardness,soil/rock a in s ze etc
�j V ft -zo ft.
4.Date Well(s)Completed: 1 Well ID# ft _SZp ft ro W^,•�,
5a.'Welll Location: Sp ft• ft. S�T� L(.` .
'lt5h r`. �PAJi Nzca.r 9G ft (3 ft
Facility/Own N e /� / Facility M#(if applicable)
ft ft
3" ,'�`' ft ft
Physical Address, and Zip G� 7 J((� ��J 2 ft ft
V q`r-
21'RF.MARKR ':.'::_: --:.`-.—.-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.C fi tion:
'S> �73 N
6.Is(are)the well(s)MPermanent or Temporary SignafL19 of Cer-09 Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well 0Yes or fiQNo with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards 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#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-,is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 5z_ww Il b SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'an�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
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: A; � �— /�-rF� construction to the following: r
(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 276994636
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: 67 rS-1��l.� Amount: J 42 completion of well construction to Ithe.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