GW1-2021-02618_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
i
1.Well Contra for Information:
_ -a.
U 14.WATER$ONFS':r- '' .. ..,.,
Well Contractor Name `�'•��'`"' Y Y FROM TO DESCRIPTION
g 2021 95 ft. �� f
NC Well Contractor Certification Number `j 1111
a 15c OUTER CASING.(for multi=cased wei15)'OR LINER if a` livable
Morgan Well & Pump, Inc. r F1�B,,;.tI1 r' FROM TO DIAMETER THICKNESS MATERIAL
9 P lisa� P.%L'VP—.,;POB
/�l�/J� 2 y +1 fL fL 61/6/ in' sdr21 pvc
Company Name �f ` / F1'OJ ! I`Z L 16:'INNER CASING OR TIIBTNG` eothermsl'dosed•loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATFRrer.
List all applicable well construction permits(i.e.WC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): fli fL in.
17:'.SCREEN::
Water Supply Well: FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public fL ft in.
il Geothermal(Heating/Cooling Supply) RZesidential Water Supply(single) ft. fL in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT'.. _Irrigation FROM TO MATF.Rrer. EMPLSCEMFNT METHOD&_4MOUNT
Non-Water Supply Well: 0 fL 20 ft bentonite poured
Monitoring EIRecovery fL fL
Injection Well:
fL fL
Aquifer Recharge Q Cn-oundwater Remediation
I9:SANDlGRAVEL`PACK if a"licalile .".:<.`.':`=.''.
Aquifer Storage and Recovery Oi•Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
_i Aquifer Test !3 Stormwater Drainage fL fL
Experimental Technology OSubsidence Control M ft.
Geothermal(Closed Loop) OTracer A DRIIJJiG LOG'fitticti sdditiddia sheets:if
Geothermal(Heating/.Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocks a rain size,etc
6 ft ld ft I 'h.r k--
4.Date Well(s)Completed:7--Z7 f'Z well ID# d fL r ft S'r+t J S
5a.Well
�Location:
'•
Facility/Owner Name / Facility/ID#(if applicable) �L ft. fL
4t
— TK'' 13�i� �i�. L 61' l Z :/'Ira, S r'rth fL ft
Physical Address,City,and Zip ft. ft
1D 10,6 y
'
�il� C�h. :$1:R ,'1
RMARKR ;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hat/long is sufficient) (� -�q 22. o
�5ggy72/ Nr' b '•�8 � 1�3 w
6.Is(are)the well(s)'Permanent or OTemporary Si o Well Conhac Date
By signing thi j rm,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ElYes or A 'o with 15A NCA 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-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: 2U (ft-) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3 cB 00'emd 22@100D construction to the following:
10.Static water level below top of casing: �/ (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
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y �Gr7 construction to the following:
(Le.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) ` Method of test: air pressure 24c.For Water Supply&Iniectidn 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: �J✓�h✓�w Amount: ��2 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016