GW1-2022-00895_Well Construction - GW1_20220107

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well C ntractor Information:
tl4f+ .14:.WATERZONES FROM TO DESCRIPTION
Well Contractor Name ft ft
4ISSd- .4 ft ft
NC Well Contractor Certification Number '15.OUTER.CASTNG;(foi•multi-eased wells)OZt LIlyEIt if"a-'licable'
Morgan Well &Pump, Inc. FROM TO TEaCKNESS MATERIAL
+1 ft 2�XDLkMMTER
/8/ in' sd21 pvc
Company Name �r I„I D(. W u /n�^ 16:IlVNFR CASING'(k eothecmal closed loo'
2.Well Construction Per #: ` f '17 FROM To DIAMETER THICHNESS MATERIAL
List all applicable well construction permits'(.e.UIC,County,State,Variance,etc.)- ft ft in.
in
3.Well Use(check well use): ft ft.
17:SCREEN',:-. ::.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_•:Agricultural QMuaicipal/Public ft ft
Geothermal(Heating/Cooling Supply) f esidential Water Supply(single) ft. ft in.
I Industrial/Commercial Residential Water Supply(shared) j18:GROUT:
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
'•Monitoring DRecovery ft ft.
Injection Well: ft ft.
J Aquifer Recharge Groundwater Remediation 19:SAND/GRAVEL'PACK>f a 'licitil'e
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft ft.
I Experimental Technology Subsidence Control ft ft
J Geothermal(Closed Loop) Tracer .20.DRILL1NG.LOG(ittic6=additidn'sl sheets if iiecess '
i Geothermal(Heating/Cooling Return) _Other(explain under#21 Remarks) FROM TO DESCRIPT ON(color,hardness,soil/rock ty e rain size,etc.
ft 't, ft [Zed P.r r
4.Date Well(s)Completed/ "? Well ID# / •\ft 12 Z ft. 0014 'r
5 .Well Location: V ft b ft y4,,tj c
��0�J C V ft. •L� ft r�iq• �-
Facility/ wner Name Facility ID#(if applicable) , O ft o ft •
1 "/I J 4,x1 (Lr) zt Le1,.irc'A (6 flILIp ft. .�GL Ii�''�°` E b...
Physical Address,City,and Zip ft ft
C���Cs(/� "21iRFMARKS=:_1i:;'_.: • .; .."c:'1.:.:._:r.:r..,:.:: `; •' .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,o e IaUlona is sufficient) • � 22.Certification:
N W
6.Is(are)the well(s) Permanent or QlTemporary Signature of Certified 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 ANo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standmds and that a
Ifthis is 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#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-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: t` SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �`y (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi tderent(example-3 00'and 2@100) construction to the following:
10.Static water level below top of casing: �� (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 (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 1 "t LI construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Iniectio I 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: �n�b`` Amount: V 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