GW1-2021-02567_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER'ZONES:r_'.' :` :.`,•:. ,:;(.:�:< i`i:-'::.•:`::. ". '...�<.; ..::. "` _.; .
Well Contractor Na e ii FJJOrd TO DESCR1PT10N
f A 20�1 0 ft 56/ ft.
572-/� Sr
3 i
, ft ft
NC Well Contractor Certification Number r a; r r��ncililJ�131$
'G', .3 -m-'OUTER.CASING.(formulti=cased'weII`s)OR.L-INER{ifa'..liratile
Morgan Well&Pump, Inc. C}�"J� '°e' FROM To DIAMETER il�cKNEss MATERIAI
+t ft ft 1 6 18/ l in. sd21 pvc
Company Name
'`���� 16i"INNER CASING OR.TUBING`(ke6thermal.'dosed=loo"
2.Well Construction Permit#: FROM TO DLANIETER THICn Ess � MATERIAL
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.)- IL
ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: - -_:....... :=_ r
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MAA TERI—ilAL
Agricultural DMunicipal/Public ft ft in.
i Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft fL in.
i Industrial/Commercial Residential Water Supply(shared)
GROVE... - -
1hri ation 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 Recharge Groundwater Remediation
19.SAND/GRAVEVPACK if i`Ui:ible
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD y
:]Aquifer Test Stormwater Drainage ft. ft
]Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 92U.DRMSJNG.LOG'fittich-idditional slieets:ff
i Geothermal(HeatinglCooling Return) .J Other(explain under#21 Remarks) FROM TO DESCRIPTION((color,hardness,soil/rock;,e, in size,etc)
O ft. /D ft retwo. (o J"
4.Date Well(s)Completed: 7 Ii -?,l well ID# i) ft 600 fr �Y0. ay&AA
5a.Well Location: ft t f
8,l( �z1 — ft. ft.
Facility/ wner Name �+ C Facility ID#(if applicable) ft t f
ljmjrl..� f"i, L�+. J h\CY N6 ft ft.
Physical Acldreks,City,and Zip T ft ft
W277 '<21iF.RMARKS:':"�_:` .
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 lion'
ss:3,qa N -'9662.2Of W 7_Z?P
6.Is(are)the well(s) Permanent or OTemporary S ignarkaAf Ce ed 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: r1Yes or%E�No with 15A NCAC 02C.0100 or 15A NCAC 01C.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: 600 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Qa 200'and 2@100D construction to the following:
10.Static water level below top of casing: so (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 Infection 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: l Y' G�Qw� construction to the following:
(ie.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
(gp ) air pressure 24c.For Water Supply&Iniection Wells: In addition to sending 13a.Yield m Z•� Method of test: g the form to
/� the address(es) above, also submitl one copy of this form within 30 days of
C'�.13b.Disinfection type: avAr' Amount: Z7oe completion of well construction to ithe county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016