GW1-2021-02380_Well Construction - GW1_20210723

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I
on: 14.WATERZONES::
Well Co a „so q� FROM ft TO ft. DESCRiPTI ON
- -A 4 r Name °moo %T, i C� c9 �iti ft ft
NC Well Contractor Certification Number I
-15'OIITER CASING.(ftir'multi=cased'we➢s)'OR L•1NER if a' lieaBle`-t.":<-:;•'.;.; .
K J 'Qr TO DIAMETER THICKNESS MATERIAL
Morgan Well& Pump, Inc. �• r�:�
FROM
9 p' �a1L1� CSP +1 ftIN6 ft 61/8/ in. sd21 pvc
Company Name Q�' 16'"ViNER CASING OR.TUBING' `cothermal'cloied-ldo
2.Well Con$truction Permit#: FROM To DL1AFTER THICKNESS �,MAT7?RTAr.
List all applicable well construction permits ri.e.NC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
1 17;'.SCREEN:;.:.
Water Su
PP Y Well: FROM TO ' DIAMETER J SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipaUPublic ft. ft �^ e
71 Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft
hidustrial/Commercial Residential Water Supply(shared) ~
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&.•MOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring QRecovery ft. ft
Injection Well: ft ft
I Aquifer Recharge Groundwater Remediation
.19:SAND/GRAVEL'PACK if
:.)Aquifer Storage and Recovery [3 Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft
Experimental Technology OSubsidence Control ft ft
j Geothermal(Closed Loop) Tracer lib.DRDaING..LOG'(atti6'idditioiial slieeti.if icaegs -)
i Geothermal(Heating/Cooling Retum) i ( P ) FROM TO DESCRIPTI N(color,hardness,soll/rock e, in size,etc)
�n _ Other ex lain under#21 Remarks a ft. )-5 ft
4.Date Well(s)Completed: I � Well ID# S ft 1156 ft'
a.Well Location
b ft ft
Faci ty/Owne Name Facili (ifa licable ft ft -.
L ft ft
Ic ft ft r >
ysical Address,City,and Zip �� f ) g]j
t F '
Si�4 S C+
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.C 'ficatio
35.0 b,1 N-Z_ ,q0!0 W l �l
6.Is(are)the well(s)fllPermanent or OTemporary M'igo
Certified Well Contractor Da-el
his form,I herebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ethis 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 421 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:ll �(;J (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q20 '/ Qaand 2 100D construction to the following:
v
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: 6I in.) 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: Its D�NX 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) I0Q Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
��/q� the address(es) above, also submit i one copy of this form within 30 days of
13b.Disinfection type: Amount: !6 bZ completion of well construction to the county health department of the county
where constructed.
i
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016