GW1-2021-02612_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: n
�. ':14.WAIERZONES*::
oracih
FROM TO DESCRU?TION
Well Contractor Name S'•�`
'357Z'>A �r P ��. �- 2021 3 � it 3l� ft. �
ft ft
NC Well Contractor Certification Number t it� -
r ', " 15c OUTER CASING(for mnlhased wells)=OR LINER if
^t�S
Morgan Well& Pump Inc. t1;`.3 '" c� '�`OD FROM To DIAMETER xfficlOVEss MATERLL
I'SO ,RI i
+1 ft 8ft ft 61/8/ in. sd21 pvc
Company Name Y '1 1
q Y6:VGgERCASINGORTIIBING`-eoth,rK"Vi'dosei11"' '
2.Well Construction Permit#: 1"3�/ FROM TO Dv+METER t'fficXIMS . D DaTERUL
List all applicable well construction permits(.e.b7C,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft. ft in.
'IT'SCREEN
Water Supply Well: FROM TO DIEAMETER SLOT SIZE THICKNESS `MATERIAL
Agricultural QMunicipal/Public ft. ft
il Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft ft in.
i Industrial/Commercial Residential Water Supply(shared) r,18:GROUT.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft- bentwite poured
Monitoring ORecoveny ft. fL
Injection Well:
_
I Aquifer Recharge Groundwater Remediation
19:SANDIGRAVEI;PACK if ii •licatile .--,:;.:. e.`.;°:=::-::' :. ''
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERL+L LNOLACEMENT METHOD^
Aquifer Test [3 Stormwater Drainage ft.
_i ft
Experimental Technology D Subsidence Control ft ft
Geothermal(Closed Loop) OTracer Lk 20.DRILLING.LOG itta'cti additional sheets":if neces's •-)-';i::.:'`.`
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc
EGeothermal(HeatinglCooling Return) J Other(explain under#21 Remazks)
ft. ISO ft. p f
4.Date Well(s)Completed: 7 23 2( Well ID 5�# ?j r ft fr 1\'1'o C
5a.Well Location: S ft ?!J ft ro._ S�
tea VOW�e1�/
7 ft 3(.10 ft
Facility/Ow er ame `` Facility ID#(if applicable) ft ft
ft ft
ft ft
Physical Address,City,and Zip
21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
field,,one la/at/long is sufficient) / 22.Ce do
95J71� N ^g�1•��fk&' W 7-Z3-21
6.Is(are)the well(s) a Permanent orO1 Temporary
Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(i)was(were)constructed in accordance
7.Is this a repair to an existing well: !Yes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well consnuction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remorks 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 i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 340 -(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi¢erent(example-3@200'and 2@I00� construction to the following:
10.Static water level below top of casing: 2OL15 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casino use,•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (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: 'P r 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) 2 Method of test: air pressure 24c.For Water Supply&Infection 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: IOfr lMB Amount: it/oZ completion of well construction to the county health department of the county
where constructed.
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Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016