GW1-2022-00898_Well Construction - GW1_20220107

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
la0.c« ��owSc,
14:.WATERZONES:'
FROM TO DESCRIPTION
We1lContractorName ft I ft
�ISS�
ft ft f
NC Well Contractor Certification Number 15:0' TER,CASING(foc multi-'cased wells OR LDgER(if'a'livable'
Morgan Well& Pump, Inc. FROM I TO DIAMETER THICKNESS MATERIAL
+1 ft ft 61/8/ in. sd121 pvc
Company Name
M 2 /j ( 16:'AVNER C' OR.T[IBING 'eothei mal c1o'sed lod' :'
2.Well Construction Permit#: V FROM TO DIAMETER THICKNESS -,MATERIAL
Listall applicable well constructionpermits'(.e.UIC,County,State,Variance,etc.)- ff. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17:SCREEN'.:*.,.—. '_;. .' .; ::::.::' >.•..;;:: ,:-''.. .:`.`:;- .. ` :?.. ..: . ° .=,
FROM TO DIAMETER SLOT STZF THTCKNESS MATERIAL
'Agricultural OMuaicipal/Public ft ft in.
I Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
- ft. ft.
I Industrial/Commercial DResidential Water Supply(shared)
::18.-GRODT::.
E hii ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft Y0 ft. bentonite poured
`.Monitoring Recovery ft ft.
Injection Well:
ft ft
_J Aquifer Rechazge Q Groundwater Remediation
19.SAND/GRAVEL'PACK ff a�llcible
Aquifer Storage and Recovery ©I!Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_l Aquifer Test [3Stormwater•Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :ZO.DPJI,LING.LOG'(ittiili`sdditidnal sli'6et§O i e6ess"" - -
Geothermal(Heating/Cooling/Retuurn)) 01 Other(explain under#21 Remarks) FROM To DESCRIP ION(color,hardness,soillrock grain size,eta)
O.ft
u� V \�\ ft
4.Date Well(s)Completed:� Well ID# / v ft p ft t s-^ 1,
VWCk
ell Location: ftyl� kr(y / (� ft 0 ft ?rt r
Facility/Owner Name / A Facility M#(if applicable) -H.—Oft. d0 ft.
ft ft
Physical ddress,City,and Zip G ft ft n
• �bn i1:xEEMARKs°-_......�,.�,
zu
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
15 -So38 N gI. 11113 . W
6.Is(are)the well(s)A Permanent or Temporary 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: QYes or f 4wo with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /�,l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Ll av (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 00'and/24a 100) construction to the following:
10.Static water level below top of casing: �1 V (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
12.Well construction method: 0Y
above,also submit one copy of this form within 30 days of completion of well
E
(i.e.auger,rotary,cable,direct push,etc.) J construction to the following:
Division of Water Resources,Underground Injection Control Program,-
FOR WATER SUPPLYY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) • Method of test: air pressure 24c.For Water Supply&Iniectionl 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: /14�+V�Okp` 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