GW1-2021-02377_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
1.We Contractor In�tion:
14.WATER ZONES'-::
i
-in
ntrac?LA
' T0�1 FROM TO DESCRIPTION
\ ft. ft.
�� `a 01) ft. ft {
NC Well Contractor Certification Number t�S 15S OUTER CASING.for multi=cased I,wells)'OR
eOG�a., 11 ( . ... L7NER"ifa-.livable:`W":`-"'1:'_;';;: .."
Morgan Well & Pump, Inc. arZ'Cc°" FROM To DIAMETER'n THICKNESS MATERIAL
ft ft
y� +1 61/81 sdr21 pvc
Company Name
16:1NNER CAS G OR.TUBING' 'eothecm's1'closed=lob
2.Well Construction Permit#: 32 FROM TO DIAMETER THICKNESS `MATERIAL
List all applicable well construction permits(.e. C,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
17:SCREEN r.::::...;
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
]Agricultural r1iMunicipal/Public ft. fr in.
J Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial OResidential Water Supply(shared)
`.Irrigation FROM TO MATERIAL EMPL.SCEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite ! poured
:21Monitoring QRecovery ft. ft
Injection Well: ft. ft
I Aquifer Recharge ElGroundwater Remediation
19:SAND/GRAVEL'PACK if a lieabl''6 .'.=_.::''_:_.".::.:;:.:'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test 0 Stormwater Drainage ft ft.
:]Experimental Technology OSubsidence Control ft ft.
Geothermal(Closed Loop) OTracer g Z6.DRMLING.LOG'{attach'additidiiO ii 6ets=rf
EGeothermal(Heating/Cooling R tum) J Other(explain under#21 Remarks) FROM To DESCRIPTION(color hardness,soil/rock type grain size etc.)
Ph ft ft 1 r
4.Date Well(s)Completed: Well ID# V ft ft.
Sa. ell Location: ;)� ft ft. YfL
ft ft
Facility/O ne e Facility ID#(if applicable) ft ft
' ft. ft. -y al Address,City,and Zip ft ft
•1`Y�,�1 117
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Q othis
:W (ZI N ` U)'� � W 12 /2/
6.Is(are)the well(s) Permanent or Temporary ontractor Da
tt
y certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: rJ1 Yes or JSNo with 15A NCAC 02C.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 1 GW-1 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: 1 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili event(example-3@200'acid 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 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 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&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 typ •. Amount: completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016