GW1-2022-00916_Well Construction - GW1_20220107

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Mc� a�
14:.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
C ft ft
J 1 py ft ft
NC Well Contractor Certification Number 15:OUTER.CASING.'adi multi,cased'wells OZt LII3ER if'a' livable
Morgan Well &Pump, Inc. FROM I TO DIAMETER THICIavEss MATERIAL
+1 ft ft, .61/81 ; in. sd21 pvc
Company Name ^ �O '
I 16 hV1VER CASING Olt-TUBING' eothei mal clo's8d lod' :.
2.Well Construction Permit#: FROM TO I 'DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cowrty,State,Viudance,etc.)- ft. ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17:SCREEN'.:,:.
pp y FROM TO DIAMETER SLOT SIZE TFRCKNESS:Yf. MATERIAL
Agricultural QMunicipal/Public ft ft in. ;
I Geothermal(Heating/Cooling Supply) JgResidential Water Supply(single) ft. ft
I Industrial/Commercial E3Residential Water Supply(shared) IS
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
'•Monitoring [)Recovery ft. ft.
Injection Well:
ft ft
-I Aquifer Recharge ril Groundwater Remediation
'19:SAND/GRAVELTAM if a "lickblB
Aquifer Storage and Recovery OSadnityBarrier FROM TO MATERIAL I EMPLACEN=T'A=OD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft
_E Geothermal(Closed Loop) OTracer :c2o.DRILLIIVG.LOG'ktti6Wditidn'sl'sli'eets.ifiiecess."'::r
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc
Z O.ft ft :V
4.Date Well(s)Completed: c t Well ID# S. ft ft
Sa.Well Location: ` S ft O-ft re .
ft. R
F ility//O r Name/ 1 Facility ID#(if applicable) LL ft ft
(✓ �!� C7 rJ�� �(� C •^fl Q/y ft ft
Physical Address,City,and Zip ft ft r
COM II.0 wex Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) ��� 22. ca on•
Ql(aJ Z N W 4:�� �Cc607�-t1-
6.Is(are)the wells) Permanent or OTemporary Signature of a Date
By signing this form,I hereby certify that the well(s)was(wet constructed in accordance
7.Is this a repair to an existing well: []Yes or IONo with 15A NC,4C 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fW out known well construction itiformation and explain the nature of the copy of thii record has been provided to the well owner.
repair under 421 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: 20 40 (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(,200'and 2@100� construction to the following:
10.Static water level below top of casing: yd (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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 0construction to the following:
(Le.auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
l
ai
r pressure 24c.For Water Supply&Iniection 1 Wells: In addition to sending 13a.Yield(gpm) � Method of test: g the form to
the address(es) above, also submit one;copy of this form within 30 days of
13b.Disinfection type:g6A4y/&-l- Amount 00L completion of well construction to th`e county health department of tfie county
where constructed. {
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016