GW1-2021-02367_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor nformation:
.14.WATERZONES.:..-'...:';.:_`'..:: :lr;::;:;
i
FROM TO DESCRIPTION
Well Contractor Name tip, 7 dt sit ft. I
"� 2or1 ft J ` ft
NC Well Contractor Certification Number '\`\ d
'U ryV'6�i -is.OUTER CASING.(for multi-;m d.wdlls)'OR LINER if
roces"m J FROM T1S DIAMETER T31CHIVESS MATERIAL
Morgan Well& Pump, Inc. r ,a nn
ar.{�'n �4nY1 +1 ft ` ft 61/8/ 'in. sdt21 pvc
F.f,r
Company Name `p,1.y`'l �t•C•�
/' �� 0 �� 16:11�NIIi CASING ORTIIBING'•`eothermal.'EEIC MESS
C(�. ^' FROM TO DIAMETERJin.
THICKNESS ^MATERLAL
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft.� �
3.Well Use(check well use):
17;SCREEN : '.:'.< ..,,..: . ....... ...: .. ..zc---_ ...:�_.• -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural QMunicipal/Public ft ft in.
J Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft, in.
I lndustrial/Commercial [3Residential Water Supply(shared) 18:GROUT:
lrri ation FROM TO MATERIAL EMPL.4CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring Recovery ft. fL
Injection Well: ft. ft
I Aquifer Recharge nJ Groundwater Remediation
19:SAND/GRAVEL"PACK if a litable
Aquifer Storage and Recovery DSalinity Barrier" FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage � ft. ft.
J Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 91b.DRU:LMG..LOG'riititli'additiooal slieets:if n'eces`s
FROM I TO DESCRIPTION(color,hardness,soiU.rock t e,grain size,etc.)
B Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) Oft. ft.
4.Date Well(s)Completed: '1 %�Z Well ID# it. v ft
p ft.
5a.Well ocation:
-ore l 1� aft t
Facility/Owner Name Facility ID#(if applicable) ft. ft.
�-Jr)uSe - rlk. 'L- kT) ft ft
ft ft
Physical Address,City,and Zip
c yza6 r
�11:RFMARTCSj''�':::'' .; :r<;:. =. : •_' _ . :; - : ',.,.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ,� 22.Certification:
�s�a8 N —�l•L13� I" O W
Tem ora S of Certified a Contractor Date
l
6.Is(are)the well(s)�Permanent or � p ry
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 ©Yes or PO No with 15A NCAC 02C.0100 or 154 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 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: :2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5_5 (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@2 'a»d 2Ql00� constriction to the following:
10.Static water level below top of casing: V (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 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: /��6 r �N construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL ILLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection 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:C7�4�:�ja✓ Amount: 1/5;-O'(. completion of well construction to the county health department of the county
where constructed.
9
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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