GW1-2021-02370_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well C tractor Inf rm ti n:
q1�
c®. •! C14.WATER-ZONE S'::
r c•
FROM TO DESCRIPTION
Well Co ct N e `� ±\} �Otl+ M ft
e�(t -4' L`
J\�1 c. U�}17 ft ft
i47Welt Contractor Certification Number rOLoS>C1� 15c OUT&R CASING.for multi=cased'wells OR LINER(if ti liitile='g'.:`._°i::"-i•'..:
Morgan Well & Pump, Inc. ,, �,�d % ctrCi'�Or FROM To DIAMETER THICKNESS MATERIAL
+1 ft 2,"t 61/8/ in. sd21 FP,
Company Name ��!!����((��// t�
9�.trIV71 � 161INNERCASING OR
2.Well Construction Permit#: f FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits i.e.0C,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft
Water Supply Well: '17;.SCREEN '.•'.::.:" . :. .z `... :�...,..,r-:; :.,.::.��_>_::.:_,..__.:::....:.: ..
PP Y FROM TO DIAMETER SLOT SIZE I THLCKNFSS MATERIAL
Agricultural QMunicipal/Public ft. ft in.
J Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) ft ft
I Industrial/Commercial Residential Water Supply(shared)
`•hri atlOn FROM TO MATERIAL .EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft PO ft bentonite poured
Monitoring QRecovery ft ft
Injection Well: ft ft
_!Aquifer Recharge 0 Groundwater Remediation
19:SAND/GRAVEL'PACK if a licable
Aquifer Storage and Recovery ©Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) OTracer i'2b.DRILUNG..LOG'{a[ta6-idditional i9iitsaf
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DEscR[P oN(c r,hardness,soiUrock ry e rain size em
ft ft. / e
4.Date Well(s)Completed: IPA 1 Well ID# ft ft.
a Well Location: ft.
Fa '
cility/Owner am AX
f a p cable) ft ft
ft
P sic al Address,City and Zip ft ft
':21:'REMARIfSa.-_;:=::<.' . ;:;',.a:,:".:�:: •'::_'. :.";:�::.';:: '.-..'::•:_":;::..;;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fielVT�
' sufficient) Q 9 22.Ce • e tion:
1 N%� /) i L /56 W fr3hzh/
6.Is(are)the well(s)wPermanent or OTernporary Si fXn,
ed Well Contractor D e
ping Z I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or �dVo with 15A NCC.0100 or 15A NCAC 02C.0100 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 I GW-I 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: (ft-) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(,mp e-3@200'and 2@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
II.Borehole diameter: 6 A (i 24b.For Injection 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 Wells: :In addition to sending the form to
• the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type _ Amount: completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Deparhnent of Environmental Quality-Division of Water Resources Revised 2-22-2016