GW1-2021-02566_Well Construction - GW1_20210901

7nt fo=
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Inv"S'�091ICK l�'rAgYI ��-7-�—
n� 14:WAfER'ZONES':
( iT FROM TO DESCRIPTION
Well Contractor Name
A p r, '2 (-�+"� ft �L/ ft
3S'l2-A SAS 7-15 ft /6 ft k
F
NC Well Contractor Certification Number 'r` 3 J i0(1
'l iavrl'�' `U -'�i• -M'OUTER CASING.(for-multi=casediivells)=OR LIIVER ifa licatile'=:.•...: >'.,::: -
Morgan Well & Pump, Inc. FROM TO DIAMETER THICKNESS MATR.RTAi.
+1 ft Z� ft
16. 61/8/ in. sd21 pvc
Company Name
'��8 "IIANER CASING OR.TIJBING'`eothermal'closed•looO:> _..._..
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL.
List all applicable well construction permits Cz.e. LUC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
17:'SCREEN::•:
Water Supply
Well: FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipaUPublic ft ft in.
_J Geothermal(Heating/Cooling Supply) �idential Water Supply(single) ft ft
i Industrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring Recovery ft ft
Injection Well: ft ft
_I Aquifer Recharge nGroundwater Remediation
19:SAND/GRAVMPACK ff a `iidble .:',a.::`=.
Aquifer Storage and Recovery O_'i Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer Zb.DRILT�IGLOG'{atta'cti sdditiogsl stie'ets:ifneccss"' -
i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
Q ft Q ft f� Ck4
4.Date Well(s)Completed:7-00'711 Well ID# ft Soo—ft- k^J y� �ht f C
5a.Well Location: ft ft !T
/')t' h, ft. ft.
Facility/O er Name Facility ID#(if applicable) ft ft
Aw naafi. & L 1 van (w NG ft ft
Pbysical Address,City,and Zip /gyp ft ft
��� !/
all:'RFM"eRKR
GQS-�l -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Cer• atton:
Tc.396 N -1J, 007729 W -7 fa
6.Is(are)the wells) a Permanent or OTemporary Signature of C rtified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or I No with 15A NCAC 02C.0100 or,1 SA 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: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 300 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I001 construction to the following:
10.Static water level below top of casing: 3� (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
pp o� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Aor i`�' 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) 5 Method of test: air pressure 24c.For Water Supply&Injection 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: Noyim, Amount: /3 Q2 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