GW1-2021-02661_Well Construction - GW1_20210901

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WELD CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well ContractauJjder ti
L°1a t" 14-WATER ZONES
Well Contr cto ame - 1 _.,3�-+- FROM TO DESCRIPTION
_ �'' i y yq ft ft.
3 Lo L 1 ft ft
NC Well Contractor Certification Number t
�, Unit 15::OUTER CASING(fair multi-cased'wells)OR LINER if a" licalile=;.
F-Ir��ty`W.sVr3 FROM DLSMETER THICKNESS MA•rFRT
Morgan Well&Pump, In A.^ I ,
Company Name ��<•:.,.•• 6 1/S/ `in' sdY21 pvc - _:
� � �](�i 16.INNER CASING OR TUBING eothermel closed-loo .' _
2.Well Construction Permit#: FROM TO DIAMETER TEXIDIESS MATERIAL
List all applicable well construction permits r.e.VIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROMGEl TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:)Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 1PResidential Water Supply(single) ft. ft. in.
I Industrial/Commercial [3Residential Wat&Supply(shared)
18.GROUT: : ..:. ,. e..: ..
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft bentonite poured
Monitoring DRecoveny ft. ft
Injection Well:
ft. ft
__i Aquifer Recharge aGroundwater Remediation
19:SAND/GRAVELBACK if ii 'livable
n Aquifer Storage and Recovery ©Salinity Bater FROM TO MATERIAL EMPLACEMENT METHOD
i Aquifer Test [3Stonnwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
s Geothermal(Closed Loop) [3Tracer 20.DRILLING:LOG'(attith'additional'slieets if necess"j
FROM TO DESCRIPTION{color,hardness,soil/rock type,grain size,etc.)
'Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks)
C) ft 10 ft.
4.Date Well(s)Completed Well ID# 10 It.
ft.
5 .Well Location: ft ft
ft. ft
Facility/OwnerNammee � �� Facility ID##l(ifapplicable) �, ft. ft
ZT& Il 1s�1 !��= 4�� �a ����� ft ft.
sical Address,City,and Zip ft ft.
"G1:r .-
ounty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one l��at/long is sufficient) _ 22.C lcation•
- N
yho '>�
6.Is(are)the well(s) (Permanent or 13Temporary Signatur f ified Well Contractor D e
By sig 'g th orm,I hereby certify that the well(s)was(were)constructed in accordance
A
7.Is this a repair to an existing well: [3Yes or fNo with 1 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 PT 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,c W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well delitt below land surface: . ] (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths!(different(example-3@200'and 2@1001 construction to the following:
M 10.Static water level below top of casing: S ) (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 foam within 30 days of completion of well
12.Well construction method: 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
j air pressure 24c.For Water Supply&IniectionlWells: In addition to sending the form to
13a.Yield(gpm) Method of test: g
(� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type Amount: 6 ] 6�r completion of well construction to tl;e county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environ mental Quality-Division of Wate4esources Revised 2-22-2016