GW1-2021-02632_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD GW -,ft, For Internal Use Only:
1.Well Contractor Information: q I
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"v' C� ! 3 14.WATER ZONES
OM TO DESCR1PT10N
Well Contrhtor Name �'`j lj !
Jn '34�•:ill i�rorAsiill. fL L
Ps- Il t't^vCl 1 t v.; 0il
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NC Well Contractor Certification Number
15i OUTER CASING.for mltsees ORLER fivaINi lible
Morgan Well & Pump, Inc. FROM To DIAMETER I TmCKNESS MATERIAL
+1 fL fL 61/6/ in' I d2l pvc
Company Name /'JIG S O —O`O
Cry/y 7 16:INNER CASING OR TUBING
' eothermal`dosed-loo i;;: "
2.Well Construction Permit#: FROM TO DIAMETERI THIclavEss MA7•t,urnT.
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) fL fL in.
3.Well Use(check well use): fL ft in.
_;,. ..
17S'.SCREEN :::.
Water Supply
Well: FROM TO DIAMETER SLOT SIZE THFCKNESS MATERIAL
J Agricultural Municipal/Public ft. fL in.
il Geothermal(Heating/Cooling Supply) Ekesideritial Water Supply(single) fL fL
i Industrial/Commercial DJ Residential Water Supply(shared) -1•18:GROUT _
_:::•...
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft bentonite poured
J Monitoring QRecovery fL fL
Injection Well: ft fL
J Aquifer Recharge �J Groundwater Remediation =
19:SANDIGRAVEL'PACK if a bcable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
]Aquifer Test !3 Stormwater Drainage ft. ft
—')Experimental Technology f Subsidence Control fL ft
Geothermal(Closed Loop) Tracer 9.Zb.DR]1UNQ LOG'-(itta'di'idditionsl sheets-ifR
Geothermal(Heating/Cooling Rewm) J Other(explain under#21 RemxK J
FROM I To DES 1PT ON(color,hardness,soiUrock a rain s ze etc
ot. l ft. Pi-r
4.Date Well(s)Completed:^ ""'�u� Well ID# , ft s"� ft W �-
Sa.Well Location: ft.
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Facility/Owner N e �iL]A Facility ID*#(if applicable)
fL ft
"/ S'? • T `�C. ��Lf Del V fL ft
Physical Address,City,and Zip fL ft
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22. ficltion:
6.Is(are)the well(s Permanent or Temporary Signature of CertifiedWe'll Contractor - Date
By signing this form,I herebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or iWo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 GIV I 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'a2 2 100D construction to the following:
10.Static water level below top of casing: V (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 Iniection Wells: In addition to sending the form to the address in 24a
h� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r \ "v/ 7 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) Method of test: air pressure 24c.For Water Supply&Iniection 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: 4'J W Amount: completion of well construction toy the county health department of the county
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where constructed. i
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016