GW1-2021-02639_Well Construction - GW1_20210723

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well C tractor Inf rm ti n:
y �
�, i _':14.WATER ZONES:::'.' :'.:' ..:: .1''.::•1:::;':(- :7"',:.:" :' .r: ".:: '. ' :";_:. .
Well Co sac[ N e ,a„ FROM TO DESCRSPTION
ft ft.
rr�l
Well Contractor Certification Number 4•v� �rO J 'FROM�f t TO DIAMETE
rpL�' 15c'O17TER CASING.(for'multi=rased wells)
Morgan Well & Pump, Inc. r.r 3�, cat R TfficlavEss MATERIAL
Company Name .J 16:'EMER.CXMNG OR TUBING``ee im sdr21 pvc
4A 4� � thermal elos`ed=loe" TERI.:
2.Well Construction Permit#: FROM TO DL•METER 'I'HIcxNEss MARRrer.
i7iDA
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.), ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 'ITSCREEN'.:.::..; ". :. -:'.,:::.. :...•__..:;<.j.::r.-
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft in•
•Geothermal(Heating/Cooling Supply) IgResidential Water Supply(single) ft ft
i 1ndustrial/Commercial []Residential Water Supply(shared)
I1Ti ation FROM TO MATERIAL EMPLACEMENT METHOD&.9MOUNT
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
Monitoring QRecovery ft ft
Injection Well: ft ft
Aquifer Recharge ©1 Groundwater Remediation
- 19:SAND/GRAVEVPACK if a `Utabl'e
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft
Experimental Technology D Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 3 21 DRMLING;LOG(ittadi"additional stieets:if uecessa"";:a.:: -`
FROM TO DESCRIP ON(color,hardness,soutrock ,e, rain size,etc)
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) M IO ft Ye ek 0
4.Date Well(s)Completed: / Well.ID# ft IL /
,Well Location: p�{ Q f
d-2
t ft.
Facility/Owner amV acility #(if a p'cable) ft ft
I Y ft ft
�l•^V�1i P sical Address,City,and Zip ft ft-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one t/lon sufficient) 9 ` 22.Ce . c tion:
t V � N%� L I&lhJ W f� `�ij✓ �j/
6.Is(are)the well(s)fllPermanent or OTemporary Si Ied Well Contractor D e
ing m,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: n es or �Vo with 15A NC.0100 or 15.4 NCAC;02C.0200 Well Construction Standards and that a
Ifthis is a repair,fell 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: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(ezam�e430200'ana!2@100D construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 A (i 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: J 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
I
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 submitione copy of this form within 30 days of
13b.Disinfection type Amount: 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