GW1-2022-00894_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W Contractor Information:
(��(��-f 0GIuS 14:.WATER ZONES c'. - a ::
FROM TO DESCRIPTION e M Well,,1Co trraactrorrName ft ft 5
LI�S`+ y ft ft
NC Well Contractor Certification Number
15:OIITER-CASING,fdr malti=cased wells)Ott L•D�'R if
Morgan Well &Pump, Inc. FROM To DIAMETER THICKNESS MATERIAL
+i ft ft 61/8/ in- sd21 pvc
Company Name �1 ►V' �/l ` �� I �� .. . _ =
16:UfNER CASING OR.TIIBING k eothermal clo'sbd-lod`
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATF.RTdT.
List all applicable well construction permits'(i.e.UIC,County,State,Variance,etc.)- R• fL in.
' in.
Well Use(check well use): ft ft
Water Supply Well: FROM TO DIAMETER SLOT SIZE THrCKNESS KMATERiAL
:)Agricultural rilMunicipal/Public ft ft in.
]Geothermal(Heatiag/Cooling Supply) Mesidential Water Supply(single) ft. ft in•
I Industrial/Commercial DResidential Water Supply(shared) ;'18:GROUT: `-
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft hentanite poured
Monitoring Recovery ft. ft.
Injection Well: ft ft
__i Aquifer Recharge nCnoundwater Remediation r. ...
19:SANDlGRAVEL'PACK >f a licalile
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QlStormwater Drainage ft. ft
_i Experimental Technology DSubsidence Control ft ft
Geothermal(Closed Loop) 13Tracer 20.DR1LLING.LOG attai:li'sdditidn'alstieetsifriecess"'
FROM TO DESCRIPTION color,hardness,solllrock e, rain size,etc.)
i Geothermal(Heating/Cooling Return) !Other(explain under#21 Remarks) ft ft
D.
4.Date Well(s)Completed: OL—11`O'' Well ID# / ft a ft. 1-4
_UVa.Well Location: CC / pft O ft�� f.�I �J / ft Oft
W ft
Facility/ ter Name Facility ID#(if applicable) �w -V �/l�_ �Ct/1�
N$SY P,�rn��Y Ho ✓St/ tLh U p
1Lul,%v l bft O�ft
Physi al Address,City,and Zip ft ft.
r\
County I Parcel Identification No.(PIN) jAN E 202..
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if�l�el��lat��issufficient)N , � ^ W 22.Certification: �;• ';
SS /�1j S S
6.Is(are)the wells)OPermanent or Temporary
S'gm e o ertified Well Contractor Date
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: ©Yes or &No with 15.4 NCAC 02C.0100 or I5A NCAC;02C.0200 Well Construction Standards 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
9.Total well depth below land surface: VV (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd8erent(example-3 a 200'and 2@100� construction to the following:
10.Static water level below top of casing: I �V (ft.) Division of Water Resources,Information Processing Unit,
Ifwoter 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'iform within 30 days of completion of well
12.Well construction method: r 0t�r LI construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY FELLS-ONLY: 1636 Mail Service Ce nter,Raleigh,NC 27699-1636
I
13a.Yield(gpm) Method of test- air pressure 24c.For Water SunDly&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: G5�`��t,� Amount: \ Jti 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