GW1-2021-02368_Well Construction - GW1_20210723

WELL CONSTRUCTION RECORD (GW-1) r7cm
al Use Only:
1.We tractor form fion: �'* lA.WA'fER7ANES::: . '".:` :. :::'-. .......
..�,
WellYnetor ame FROM TO DESCRIPTION
e " f�oe11 t ft.
!.`
�� a, �� 1� ft ft
NC Well Contractor Certification Number
�s�n')
Up 15i OUTER CASING.(for multi-cased we➢3)'OI2'LIlgER if a livable
Morgan Well& Pump, Inc. 6;,s3� r� t.�rJt� FROM TO DIAMETER THICI4VESS MATFUAL
a. E�` +1 ft fit 61/B/ in. sd21 pvc
Company Name
I6PINNER CASING OR,TUBING'66theimsl.'tSlos`ed=lod" s::
2.Well Construction Permit 4:F1 I I FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft• ft in.
3.Well Use(check well use): ft ft in.
W 1 17:SCREEN:e7.."..:
Water Su
PP Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERTAL
Agricultural OMunicipal/Public ft ft
J1 Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft ft in.
—
i 1ndustrial/Comrnercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring EIRecovery ft ft
Injection Well:
ft ft ,
-!Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL'PACK if if `livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL FrMPLACEMENT METHOD`
:,)Aquifer Test Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 21 DRaiDNG.LOG'{attacli-idditional stieets:if recess '.: '_
1 Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) FROM ToMDESCR14TIOtq(col r,hardness,soil/rock e, rain size,etc.)ft 4.Date Weli(s)Completed: Well ED# ft ell Location: ft yft. AKUY1
acility/Owner Name Facility ED#'(ifapplicable) ft ft
Lt-+* to Yi ik®w. . a Y rt / 1�7� ft ft
Pbysiicaall Address,City,and4p
4 ft ft
�,■��� � O� 21:REMi�RKS;...;:_:::: z:.:. _- -.-- - - - : _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. tification;
3�, 5Y N Zt/ 1Z-5)
W
6.Is(are)the well(s)ImPermanent or OTemporary a Certified Well Contractor Date
By signs this form,1 he-ebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or NNo with 15A NCAC 01C.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#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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: a/�] SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L "" (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@200'and 2@100D 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 Injection Wells: In additioon to sending the form to the address in 24a
i� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gP ) air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield m Method of test: g
1 /� the address(es) above, also submit[one copy of this form within 30 days of
13b.Disinfection typ T1 _ Amount: lot, 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