GW1-2021-02378_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor nforma'
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14.WATER'ZONES::-
FROM TO DESCRIPTION
Well Co ctorNa des ft ft.
ft ft I
We 1 Contractor Certification Number a fjde- 11
Ct� -is.OUTER CASING.(f& =cased
Morgan Well & Pump, Inc. multi
q��� +' FROM TO DIAMETER THICKNESS MATERIAL
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t^`—��, 16:IINNER CASING OR"TUBING' eti in' sd21 Pvc 1
Company Name
r ther`mal.'closed-loin =
2.Well Construction Permit#: Vl;/ FROM To DUMETER THICKNESS MAC unTer.
List all applicable well construction pe (s .e.UIC,County,State,Variance,etc)- fr ft 1°'
3.Well Use(check well use): ft ft in.
17i'SCREEN:;:'.:'..<'
Water Supply Well: FROM TO DIAMETER SLOT SIZE TffiCKNESs MATERTAL
Agricultural QMunicipal/Public ft. ft in.
-il Geothermal(Heating/Cooling Supply) PResidential Water Supply(single) ft ft in.
Y8:GROUT:
=j Residential Water Supply(shared) _-
{._ ". -
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 RechargeGroundwater Remediation
19:SAND/GRAVEL PACK rf a `livable'
Aquifer Storage and Recovery EJ Salinity Barrier FROM TO MATERTAI: EMPLACEMENT METHOD'
Aquifer Test [3 Stormwater Drainage ft ft
—')Experimental Technology Subsidence Control ft ft.
Gmthermal(Closed Loop) OTracer N Zo.DRIIS IINQ.LOG{ittach'iddidihig ihe'ets-if
FROM TO DESC91PTI N(color,hardness,soiUrock e, rain size,etc
i Geothermal(Heating/Cooling Return) J Other(explain under 421 Remarks) ft ft
tea
4.Date Well(s)Completed: Well ID# 2
ft ft
Sa. ell Location: q0
ft. ft-
ft ft
Facility/Owner ame Facility ID#(if applicable) ft ft.
ft ft
P I Address,Ci and Zip ft ft
lul -- -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.C ' lcation�y y'
t � N Wt w L
6.Is(are)the well(s)OPermanent or OTemporary 2U'.-ol
rtified Well Contractor
form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or JMNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell 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: 2610 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-E 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
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: 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&Injection Wells: In addition to sending the form to
ov 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.
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016