GW1-2021-02663_Well Construction - GW1_20210901

i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well actor Inf A �-.-_�����
;._9
14.WATER ZONES
Well acre for _ ,l FROM TO DESCRIPTION
ft.p
'LJ� fi .�•. iiiJ C�nll ft. f
n� t j
NC Well Contractor Certification Number I!;f�i!:3 ^'f ' "e
15::OUTER CASING(for multi-cased wells)OR LINER if a"tiralile
Morgan Well &Pump, Inc. �u f'``' on FROM I I TO DIAMETER TEICIUNESS MATERIAL
+1 ft ft. 61/81 in. sd21 pvc
Company Name ' 16FROM TO DIAMETER
.DWER CASIN OR TUBING eoth erm'al dosed400
2.Well Construction Permit#: ".'��' THICF4�'ESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft ft in.
CSWater Supply Well: FROM TO DIAMETER SLOT SIZE TFITCKNESsMATERIAL .
Agricultural QMunicipaUPublic ft. ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft fr, in.
i Industrial/Commercial Residential Watei Supply(shared) 18.GROUT: ::'.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. bentonite poured
Monitoring QRecovery ft. ft
Injection Well: ft, ft
i Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL'PACK rf a 'licalile
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL EMLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental TechnologySubsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20.11 IlVG..LOG(attach'additional beets if iiecess
Geothermal(Heating/Cooling Return) r Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
rt 1 ft. i 3 ft.
4.Date Well(s)Completed: J4 '! Well ID# ft. ` fr.
a.Well Locatio ft ft
` .. ft. ft
Facili /Owner N e Facility 1D�4(if app�licca�ble) I ft t f
J , Aa ft fr.
ical Address,Ci d Zip
Oar ......;
County Parcel Identification No.(PII,T)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
W
6.Is(are)the wells)JRPermanent or OTemporary Sig45A
of ified Well Contractor Date
By orm,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well• nYes or NNo witNCAC 02C.0100 or 15.4 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 remarky section or on the back of this form.
23.Site diagram or additional well;details:
8.For Geopro /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
constructi o 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 epth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100� construction to the following:
Y 10.Static water level below top of casing: 11�0 (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: it �� 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)_(0 _ 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!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