GW1-2022-00867_Well Construction - GW1_20220107

s. � �
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
l7ntnLcor Information: �
•14:.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3 S � s ft ft
'rJ ft ft
NC Well Contractor Certification Number 15:OIITER CASING',(foc mul&dued'we11s O,B LJNER if a-'livable'
Morgan Well&Pump, Inc. FROM TO DIAMETER TffiCKNESS MATERIAL
+1 ft1117
ft- 1 61/8/ ia' sd121 pvc
Company Name
16:INNER CASING OR TQBING' eother'aial closed hod'
2.Well Construction Permit#: FROM TO DIAMETER i THICKNESS MATERIAL
List all applicable well construction permits'fl.e.UIC,Couin,State,Ymiance,etc.) ft ft in.
3.Well Use(check well use): ft ft. in,
Water Supply Well: 17:SCREEN'.:,:. ..:.
PP Y FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural n
iMuaicipal/Public ft fL in,
I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft
I Indusiria]/CommercialResidential Water Supply(shared) _
.'18:GROUT
.'.
".:
E In1 ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft' bentonite poured
'Monitoring ORecovery ft. ft.
Injection Well: ft ft
_I Aquifer Recharge E_:t Groundwater Remediation
- :19:SANDlGRAVEL'PACK if a •licililb -
'Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL FrMPLACEMENT'METHOD
Aquifer Test E3 Stormwater Drainage ft ft
i Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRMJJNG.LOG'(ittiiE-ddilidi'iI slieets if iiccess""
FROM TO DESCRIP ION Jeolor,hardness,soil/rock type,grain size,etc)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft Z/p ft 1W 1>.-
r
4.Date Well(s)Completed:I2� ^21 Well ID# D ft. 740 ft (ON4 V.
5 .Well Location: G ft 110 ft MWA
h !� CI ft- /✓t `L J J%As
Facility/ ner Name Facility ID#(if applicable) ft ft
ft. fL
PbyZ. ,Address,City,and Zip ft ft 7
�s� 3s�g- -qq►y
O�r 21;'REMARKS'"'
County/ Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if 1 field,one lat/lon g is sufficient) _ � '( 22.Ce " cation:
33 Z
- 9 N � W �temper �' 2vZ
6.Is(are)the well(s)p.Permanent or J Temporary Si, a of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Owes or WWo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis it 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 421 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 I 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd8erent(example-3©200'and iV00D construction to the following:
10.Static water level below top of casing: U (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 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: 0 Y L' construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) J '
Division of Water Resources,Underground Injection Control Program,
n FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniection'Wells: In addition to sending the form to
�f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type Ci*101et Amount: l��dZ completion of well construction to the county health department of the county
where constructed.
Form GW-I Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016