GW1-2021-02654_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.WAU qontra.ctor I ormation:
14.WATER ZONES
Well Contractor Name ""' FROM ft ft.
TO I
DESCRIPITION
�j Spa` 021 i� 11
2
S�' Aft ft
NC Well Contractor Certification Number
(for
J r.L toitilC� Ullii -15i0UT'ER CASING. �mulli=cased'we➢s)'OR L•INER-if a- livable
Morgan Well & Pump, Inc. 4'^ FROM TO DIAMETER THICKNESS MMATERIALjl i'3fm3-t "",3 6:,r_;•ri(lil +t ft ft r..v6- 6 1/6/ in. sd21 pvc .....:
Company Name GQ
L� lC� 16:'II TNM CASING OR.TUBING``eothei'mal`e16s'ed-lob' >°
2.Well Construction Permit#: FROM I TO DIAMETER I TEacxNEss MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft in.
17:.SCREEN:'.-::.'..
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
-IiAgricultural MMunicipal/Public ft ft. in.
_JJ Geothermal(Heating/Cooling Supply) J%Vesidential Water Supply(single) fL g, in.
i Industrial/Commercial Residential Water Supply(shared)
:18:GROUT.: -
Inn ati0n FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring Recovery ft ft.
Injection Well: ft ft
_I Aquifer Recharge rJ Groundwater Remediation
19:SAND/GRAVEL-PACK Cif ipplicable
'Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL CEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer AI)RUIING..LOG'fisto'cti-addition lsli66d.lf6ecegs _::
1
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil rock rain size etc)
i
Q� O ft � ft. ID-, r�
4.Date Well(s)Completed:U Well ID# 2p ft S15 ft
ft. Qft. ..tom
Sa.Well Location`: / / ` — '
44 cN�I �eL L[�C rAA:'-C.
Faciil(i�,tyy/Owner Name `1 /� Facility ID#(if applicable) ft. ft
1�cNel1 `n �C)b�VAtV_ f. ft
Physical Address,City,and Zip ft ft
�✓ti?J��� ��63� 62, E-010S:,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) q 22M,71ificatii;;�:
6.Is(are)the well(s)&ermanent or Temporary Signature of Certified ntractor Date
By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or$No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
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.If
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-I 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: 6V (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi�'erent(example-3Qa 200' r//d��2 a@100� construction to the following:
10.Static water level below top of casing: KU (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: A 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(gP m) _ Method of test: air pressure 24c.For Water Supply&Iniectiori Wells: In addition to sending the form to
—
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: U —Amount: O'Z 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