GW1-2021-02379_Well Construction - GW1_20210723

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ConA MA tractor Informati n: � 14:WATERZONES'==-'.'
I i
FROM TO DESCRIPT ION
�n Va
ft ft
ft ft
NC Well Contractor Certification Number <s
i ," -is'. CASING.(for'multi=cased well`s
Morgan Well& Pump, Inc. `6 �` �-O �`���` FROM I To DIAMETER MATERIAL
+1 ft. 127� ft 61/B/ in. sd21 pvc
Company Name e$� 16i"II9NER CASING OR.TIIBING'"eotheimal.'closed=loo
2.Well Construction Permit#:_( 7 1 ;;'t�� C FROM TO DIAMETER THICIOVESS „MATERIAL
List all applicable well construction permits(i.e.IUC,\ ,st JWTN r�ahance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
I V SCREEN::,:.::.
Water Supply Well: :,.::;.•.',_:�'::;''_::.�:..-:.;a::-=-.::,...._=�_..,�_....:...,.,.. r
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft ra•
J Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ft g,
I Industrial/Commercial Residential Water Supply(shared)
IiTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
Monitoring ORecovery ft. ft
Injection Well:
ft ft.
!Aquifer Recharge rJ Groundwater Remediation
19:SANDIGRAVEL`PACK Cif a `licalile .:::":::�`=";>'::;:- ,:' •,,;
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
)Aquifer Test [DStormwater Drainage ft. ft
)Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 926.DRUIING.LOG'{ittiEE'sdditi6iiilsliaets:ifiecds .. F:v.
FROM TO DESCRIPTI N(color,'hardness,soil/rock e, rain size,etc.)
EGeothermal(Heating/.Cooling Return) J Other(explain under#21 Remarks) P,� ft. f�. ft Y 1
4.Date Well(s)Completed•l.—P—J5, C11 Well ID# ft L� ft 0 T47
5a. ell Lo is ft. ft. O
! ft ft
Faca ky/Owner Name Facility ID#(if applicable) ft ft
ft ft
UN
ical Addres C ,and Zip ft ft
Im r
:21:'RFMARKS I';'='1':�. .. ,.. _.,._'. .::.:.:...... ..._:: . -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Cei•' ation:
N 9%J '� U W //IJ
6.Is(are)the well(s)iwermanent or MTemporary sign C ified Well Contractor Da e
By sIo ,ng t ' orm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or NNo with 15,4 NCAC 02C.0100 or 15.4 NCAC&C.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 ofthisform.
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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:�� �.v (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii erent(example-3�@il 00'mid 2@1000 construction to the following:
10.Static water level below top of casing: L)u _(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 P•) r 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: construction to the following:
(Le.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
�j the address(es) above, also submit lone 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