GW1-2021-02382_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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ntr r on: f
Jaa ���� p,'L 14.WATER'ZONES:::
Well for Name w FROM TO DESCRIPTION I
ft
�3z ti�ED �O \(�� 15:OIITER CASING for multi cased,
ft ft.
NC Well Contractor Certification Number d VC,\ wells OR'
J a 5 `' ( . , .... ... ,. LINER if a' liialile 7Y:.�:
Morgan Well & Pump, Inc. ra��. FROM I TO DIAMETER I THICKNESS . MATERIAL
+1 ft ft 61/81 I in. sdt21 pvc
Company Name �,yOC\�
� � 16!VI NM CASING OR TUBING'-edtheral:mclosed-loa t` _
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.07C,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17;'SCREF.N':•:::..
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft in.
71 Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&.•MOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring DRecoveiy
Injection Well:
ft ft
_I Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL'PACK(if if licablii'..::<`.::::=.''.i`:�:•.: ,
Aquifer Storage and Recovery D_'i Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_Aquifer Test [3Stormwater Drainage ft ft-
Experimental Technology USubsidence Control ft ft
Geothermal(Closed Loop) Tracer L42b.DRIIiLTNG..LOG'(iittii6-additionaIiE6'is:d
FROM To DESCRIPTION(col r,hardness,son/rock type
'Geothermal(Heating/ i Cooling Return) Other(explain under#21 Remarks) in size,etc
ft f�ft
r
4.Date Well(s)Completed: Well ID# >1' ft 35 ft.
4 Well
yLocation,
Facility/ a erne Facility ID#(if applicable) ft ft
sisal Address!City,and Zip ft ft
9,V\ Ito ,1
':21:'REMARKS:":r:__:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lonQ is sufficient) 22 r (cation:
.'t� N� 31, W �' 1
6.Is(are)the well(s)J§Permanent or DTemporary Sig Jo ertified Well Contractor Da e 11
gfm,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existingwell: Dyes or ®No with 15C 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: 3co A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 00'and 2(a310q 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 24b.For Iniection Wells: In addition to sending the form to the address in 24a
e
�— 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 WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1<.! Method of test: air pressure 24c.For Water Supply&Iniectio I 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 type 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