GW1-2021-02633_Well Construction - GW1_20210901

IL PrintForrn
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
1.Well Contractor Information: _
-
U.�41 14.WATERZONES'::- .' :'.:i'.:._ ,:;!::..•:-:.;:�-:. -.`".: .'::;::. .' :.•.. ..:?.:.
�_ye FROM TO DESCRIPTION
am Well Contractor Ne 0 yy
20 L 1 150 ft '`I ft.
35T2-
ft l
Sty i,, ft
NC Well Contractor Certification Number
r�r Jr Dam cif lC 15:OUTER CASING.(for mniti=cased wells)'OR'][MiER if ii livable`i'..`•._: `,:
Morgan Well & Pump, Inc. Y' 41+^.�r� :�;o� FROM TO DIAMETER THICKNESS MATERIAL
v`` +1 fL -I g ft 6 1/6/ in. sd21 pvc
Company Name
''f9 :16:INNER CASING OR.TUBING` eotheiiniU-dos'ed400'
�7 .'- -
2.Well Construction Permit#: -752W— FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17:.SCREEN:',:>.:'. '. =. :.�,^..,.,.=.:_.::. ;;.-:,..>_-,.-,_,,� ,:_�::=r_.. ,�_..,:;<:.,.-•. _..;
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) gfr-idential Water Supply(single) ft ft in.
i Industrial/Commercial Residential Water Supply(shared) ;18:GROUT.: - _
Irrigation FROM TO MATERLIL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft Y0 ft bentonite poured
Monitoring ORecovery ft ft
Injection Well:
ft ft.
_I Aquifer Recharge ©J Groundwater Remediation
19:SAND/GRAVEL'PACK if a�livable =.". '::::.:`' ;;'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft
_;Experimental Technology 0Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 9 2b,DRILLING.LOG'ittac6 additional
i Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soUlrock type,grihi size,etc.)
Q ft ft
4.Date Well(s)Completed:Z�22-2 l Well ID# k/I ft ti' SQrI
/ ft. lb ft' •
Sa^.Well Location: 1 ( O
I V ler 6oAk0,Yd ft ft
7
Facili /Owner Name Facility
ED#(if applicable)�y� ft ft
LIID Pow)owK�a pr
Ch\I�r� l7�vb,(el J�l�,° 2 w2T ft ft
Physical Address,City,and Zip ft I ft
Gwayt -f7- 1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce
S. 67.16 T7 N -g� �171Q� W cati
VI
6.Is(are)the well(s) J Permanent or OTemporary Signature of Certified 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: E]Yes or 10<o with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Stan&ds 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3ta 200'and 2Q100� construction to the following:
10.Static water level below top of casing: .20 (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 Infection Wells: In addition to sending the form to the address in 24a
� n above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:y re, 1lf 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&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: Qqd1rj0l8 Amount: 701, 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