GW1-2022-00878_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
I
1.WeIL,Tnc or Information•
I v 14.WATER ZONES
FROM TO DESCRIPTION c
Well Contract N e ft. ft
3�} A I
� ft ft
NC Well Contractor Certification Number 15:OUTER,CASING,(foi•rnuli-.,6s d we]Ls 02£LIlYER if'a"livable' "..':
Morgan Well &Pump, Inc. FROM TO DIAMETER TEICIaMS MATERIAL
+1 ft. ft i 1/B/ �' sd21 pvc
Company Name = �' ,7
P�� 16.INNER CASING OR TUBING eothei mar closbd rod'
2.Well Construction Permit#: -7- FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'(r.e.UIC,County,State,Ymiance,etc.)- ft ft' tn.
3.Well Use(check well use): ( ft. ft in.
17."SCREEN', ' '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS TMATERIAL
:'Agricultural QMunicipal/Public ft ft in.
I Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) ft. ft in.
I Industrial/Commercial DResidential Water Supply(shared)
Irrigation 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 [3Groundwater Remediation
•19:SAND/GRAVEL'PACK if ii'licalilb
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft
_I Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) LYTracer :20.DRILLING.L0G'Wtii1i_ddition'alslieetsifiiecessa" ':;: ' ':': 777771.•1
Geothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock ty ratn size,etc.
6 ft 115 ft
4.Date Well(s)Completed:IZ V Well ID# l5 ft 35 ft
ft ft.
5 Well Lora' n _ y�
ft ft �/a ���y r ��a_
Facil / ner Name S Facility M#(if applicable) ft ft
ft ft. iAN
O�?
Physical Address, ,and Zip �/�� /�� f t
�i�fr�t�I ?610 RF.MARKR'. l..
2I:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. tification:
35- 7= N --fib gb W _�J —
�2
6.Is(are)the well(s)mPermanent or OTemporary
Sign e o ertified Well Contractor Date
By 'Wing s form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or INNo with 15A NCAC 01C.0100 or 15A NCAC,01C.0100 Well Construction Standards and that a
If this is'a repair,fill out known well construction information and explain the nalur•e of the 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
9.Total well depth below land surface: J it JU (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: �y (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 Injection 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: 'r 0 1 ".�—/`�t r L� construction to the following:
(Le.auger,rotary,cable,directpush,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) Method of test air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit Jone copy of this form within 30 days of
13b.Disinfection typ lnYtVN&'b Amount: 12 az 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