GW1-2021-02647_Well Construction - GW1_20210527

Print Form;,_ '-
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ontractor Inform o
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':14:WATER ZONES ... _ .. . .r., . .;..,
FROM TO DESCRIPTION
Well Contract N e
ft ft. �
��q2t? ft ft. ft
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased.wells OR LINER if a" lica6le;r
Morgan Well & Pump, Inc. FROM T DIAMETER THICKNESS MATERIAL
+1 ft. ft 61/8/ in' I d21 pvc
Company Name
�//yy����(�(�] 16:-IIVNER CASING OR'PUBING`(_eothermal
2.Well Construction Permit#: �V 1 /4l FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permit�IC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SFROM C E TO DIAMETER SLOT STZE TfnCKNFSS ~MATERIAL
J Agricultural [3Municipal/Public ft. ft in.
_i Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft ft in•
i Industrial/Commercial Residential Water Supply(shared)
,18:GROUT ;
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring DRecovery ft. ft.
Injection Well:
ft ft
Aquifer Recharge0_J Groundwater Remediation
19:SAND/GRAVEL'PACK if if lidalile'..
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test !3 Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft ft.
J Geothermal(Closed Loop) Tracer T,10.DRILLING.LOG:.(2ilttacli'additidn:9 sli6ets if 6&ess ;;
Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock a rain size etc
- p ft 16 ft bf Out h 1r
4.Date Well(s)Completed: ) Well ID# l© ft ft. r, V 8C
5a`.Well
'L ft ft
/�•�V� S���y r ft ft
Facility•/Owner Name FacS�4 ID#Qfapplicable) ft. ft
�� (L�lTrd� �Vl•IAA �\ ti���/� ft ft �
sical Address,tity,and Zip ft
11.RRMARKS;'.
County 1 Parcel Identification No.(PIN) 2021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) f3C>-ae7X5 0Z,6 N W 174
=i' r�lli; ilvn t
6.Is(are)the well(s)o Permanent or OTemporary Si a e Certified Well Contractor Bat
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or ONo 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 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: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@a(2000'and 2Q100� construction to the following:
10.Static water level below top of casing: ! 5 (ft.) Division of Water Resources,Information Processing Unit,
If water 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
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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 Ce tinter,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: Amount: completion of well construction to ,he county health department of the county
where constructed, i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016