GW1-2022-00891_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1 Well Contractor Info'ration:
•14:.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
�( ft ft.
ft ft
NC Well Connector Certification Number 15:OUTER.CASING:(foi multi=rasea wells OFt LIl�R if'a' livable'
Morgan Well &Pump, Inc. FROM TO DIAMETER TffiCRNESS MATERIAL
+1 fL Q1 ft 61/8/ in' sd21 pvc
Company Name
16
((�'IL// L o "INNER CASING OR•T[7BING'•eothefifial ola'sed loo' :'
2.Well Construction Permit#: FROM I To I DIAMETER I TffiCKNESS ' MATERIAA
L
List all applicable well construction permits'ri.e.V7C,County,State,Variance,etc.)- ft ft. in.
3.Well Use(check well use): ft ft in.
1 17:
Water Su SCREEN'.:,:. .;. `:,. .`.,. =`_.:::.:... .:..,.; ;'.. •::.::-?..
Supply Well: FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural rilMimicipal/Public ft ft in.
i Geothermal(Heating/Cooling Supply) INResidential Water Supply(single) fL ft in.
i Industdal/Commercial JDResidential Water Supply(shared)
GROUT.'
Irrigation FROM TO MATERIAL EMPLSCEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. bentonite poured
Monitoring Recovery fL ft.
Injection Well:
ft ft
_.J Aquifer Recharge [Groundwater Remediation
�:19:SAND/GRAVEL'PACK if ii '•licatil'e �• „ : - � `:
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING.LOG'(attac6'edditiun'al
FROM TO D PTI N color,hardness,soil/rack type,grain size,etc
i Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ow ft
4.Date Wells)Completed: a-1 Z Well ID# d, fL 6v ft.
5 .Well Location: O ft �ft now fij,C :1 i'.T,F�lr i•,,� /�::
D` ` ft ft r v
Facilityy . a �r U {� l_c ty M#(if applicable) ft ft. A, 7
� O LD tc �� ft ft
L
Physical Address,City,and Zip
IL RFM
ft ft j'•�� I V��ZJ/ ARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in de.-rees/minutes/seconds or decimal degrees:
(if well field,one lattllong is sufficient) �� 22.Certification:
Si, a of Certified Well Contractor Date
6.Is(are)the well(s) Permanent or OTemporary
By signing this form,I hereby certify that!the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or P}No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair fill out known well consn•uction information and explain the nature of the copy ofthis record has beets provided to the well owner.
repair under#21 remarks section or on the back ofthis 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-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: ydv (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 a 200'and 2 J00) construction to the following:
10.Static water level below top of casing: L '6 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino 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: Y LI construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPDR
LS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
air pressure 24c.For Water Supply&IniectionfWells: In addition to sendin 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:A!`Cpvte'— Amount: /�-G 'I- 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