GW1-2022-00892_Well Construction - GW1_20220107

i
nt Form :.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: f
1.Well Contractor Information:
I
14:.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name Ua "- -M ft
/�s-Ia \6\-
ft ft
NC Well Contractor Certification Number 15:OUTER.CASING•(foi•multi_'dised•wells 0,R LINER ff a'licablel ji
Morgan Well& Pump, Inc. FROM o DIAMETER TffiCKNESS MATERIAL
/ +1 ft j1 ft 61/8/ i in. sdr11 pvc
Company Name E
'A,iJj Q qq 5/)('t/'�/( l/r v IC INNER CASING OR T[JBING eothermal closed-mod`
2.Well Construction Permit#: FROM To DIAMETER THICKNESS ` MATERIAL
List all applicable well construction permits'(i.e.WC,County,State,Variance,etc.)- ft ft. in.
3.Well Use(check well use): ft % in.
-
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERTAL
:Agricultural -iMunicipal/Public ft ft in.
i Geothermal(Heating/Cooling Supply) NResidential Water Supply(single) ft ft in.
i Industrial/Commercial J Residential Water Supply(shared) _
Y8i GROUT:..
Ini ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft. bentonite poured
'.Monitoring []Recovery ft ft.
Injection Well: ft ft.
_I Aquifer Recharge Q Groundwater Remediation
19:SAND/GRAVEL'PACK if a •licibre "
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL FrMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft ft
i Experimental Technology []J Subsidence Control ft ft
Geothermal(Closed Loop) []Tracer :20.T)RILLiNG.LOG'(ittii lP dditidn'sl slieetsjf neces's-�)t-. ' '
FROM TO DESCRIPT)ON(color,hardness,sail/rock ty in size,etc)
I Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) G ft v ft t
I I .
4.Date Well(s)Completed: t •` 1 Well ID# / �/, ft 1/0 ft
Sa. ll Locatio l 1 D ,, U ft IQ t f
fL
Facility/o^e Name applicable) t. tuftft
�V ��cA' .L. �•\• -l:f.
Physi Address,City,and Zip / rA\ {/�� ft ft JAN 7 202
�,/LV 1� v / �1,/�V O '21:RFMARTC4'- `:r•� - -
,;r,' ;C:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well one at/1 isVint) p // �- 22.Ce c do� IN I� I.1 7(ts W tGUA
6.Is(are)the well(s) Permanent or []Temporary• Signa of Certified tractor D
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©'Yes or ©No with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under,#21 remarks section or on the back oflhisform.
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: 6 2 V (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 2@100) construction to the following:
� u
10.Static water level below top of casing: (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 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: r O Y L` construction to the following:
(Le.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) 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: Y Amount 0 completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016