GW1-2022-00858_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
TellContractor Information:
Y i V 14:.WATER ZONES,,'. - ::;:.. `.. ::` :.
7.
We on�torName FROM TO DESCRIPTION
(/f� r ft ft
ft ft.
NC Well Contractor Certification Number 15;OUTER CASING,06e multi-&lisea wells OR LMVER if a" lirSble
Morgan Well &Pump, Inc. FROM I TO DIAMETER THICKNESS MATERIAL.
+1 ft 16t ft 61/8/ in. s421 pvc
Company Name
1CINNER CASING OR TUBING"eothermal closed loo' :'.
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits'(z.e.UIC,County,State,Ymiance,etc.)- ft ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17:SCREEN',:
FROM TO DIAMETER SLOT SIZE -THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Di Residential Water Supply(single) ft. ft in.
i Industrial/Commercial Residential Water Supply(shared) _
1S:GROUT.'
I1Ti ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft 20 ft bentonite poured
Monitoring ORecovery ft. ft.
Injection Well:
_I Aquifer Recharge [3,Groundwater Remediation ft ft
'Aquifer Storage and Recovery Salinity Barrier FROM/GRTO L PA
13 MATERIAL e 'EMPL ACEMENT.l1ETaOD
Aquifer Test E3Stormwater Drainage ft ft
_i Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer ZO.DRILLING.I OG'attali'additional'stieetsif iiecess"'j';' =>":=
Geothermal(Heating/Cooling Retum) -Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc
ft ftRAJ .f
4.Date Well(s)Completed: Well ID# / ft. ft. fa&JA b'
52.Well Location:
4ew 1,�f- d eve �S / t c,ft
Facility/Owner N me FacilityM# if a H able ft J ft /
n Iti"�•,+. �
Physical Address,City,and Zip ft ft 1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwel ei one lat/long is sufficient) 2209���
S. q,537Y N go.6 CJ18'6' W 6 z
�z
6.Is(are)the well(s);0Permanent or OTemporary Signature of Certified Well Contra Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or QNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standmds and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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
ad%Total well depth below land surface: ��U (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q100D construction to the following:
10.Static water level below top of casing: V (ft) Division of Water Resources,Information Processing Unit,
Ifwater 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: r0 Y LI construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WALLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(gp ) ,(/ air pressure 24c.For Water Supply&IniectionlWells: In addition to sending the form to
13a.Yield m Method of test: g
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: «del)�� Amount: y� completion of well construction to the county health department of the county
where constructed. l
Form GW 1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016