GW1-2021-02364_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well�ontrastor Inf r afion:
( ,^1 FROMATER-Z ONES:.-. . .'TO DESCR1PT10N rar:
Well Contractor Name ft
3 J 1 ft ft
NC Well Contractor Certification Number
JU v1 *,tSd OUTER CASING:(for m ulti=cased'wetii=OR L^II MR if a"Plicatile=
Morgan Well & Pump, Inc. eao,3 FROM To DIAMETER THICKNESS MATERIAL
9 p,
tVIR 16.INNER CASING OR UBING' eo to sd 21 pvc
- ft. ft
Company Name ��'" -
r((J••�� ��, therma`1`elosedlod
�� FROM TO DIAMETER THICKNESS MArRRrer.
2.Well Construction Permit#: 1►y
LW all applicable well construction Perm iu r.e. UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft in.
'17i SCREEN:'.::.:'... -
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS —MATERIAL
J Agricultural Municipal/Public ft ft �•
J Geothermal(Heating/Cooling Supply) �sidential Water Supply(single) ft ft in.
i Industrial/Commercial Residential Water Supply(shared) --
:15:GROUT.. ,'..`::;a, .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
'.Monitoring QRecovery ft ft.
Injection Well: ft ft
Aquifer Recharge Cnoundwater Remediation
19:SANDIGRAVEL'PACK if a 'livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
: Aquifer Test [3 Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer2U.DRILLIlVG.LOG'{attar]i'additionalsitieeMI ts:rfiiecess"") =::
FROM TO DESCRIPTION(color,hardness,soil/rock e, in size,etc.
Geothermal(Heating/Cooling Return) I Other(explain under#21 Rem 'ks) ft U ft.
�,r
4.Date Well(s)Completed- IS ZI Well ID# v ft o ft ea IW n
ft V ft. S0l
Sa.Well ovation: e fL
!,
Facility/Owner Name , n Facility ID#(if applicable) ft ft
[2� 13)1 e S ! D �f�/'11 Cif ft ft
Physical Address,Ci ,and Zip ft ft _
ed <` 61N-131 -7016
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ell ld one lat/long is sufficient) 22. ertifivation•
6�y Z7� N 40, 9 73 r�3 w Al
6.Is(are)the well(s)Mermanent or 13Temporary Sign of Certified 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: Dyes or JJVo with I5A NCAC 01C.0100 or 154 NCAC 01C.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#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 G�✓-1 is needed. Indicate TOTAF(f�
ER of wells construction details. You may also attach additional pages if necessary.
drilled: -22 . — � 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 if dierent(example-3(a 200 /Q�100D 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 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,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&Iniectio�n 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: Ko Amount: �o�L 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