GW1-2022-00917_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Infor a'on:
14..WATER ZONES
FROM TO DESCRIPTION
Well Contract ame ft ft
32z� ft ft
NC Well Connector Certification Number 15:OIITEdt_CASING,(foc multi irsed'wells OR LIMIER if a
Morgan Well &Pump, Inc. FROM ro DIAMETER THICKNESS MATERIAL
+1 ft ft 6118/ in
sd21 pvc
Company Name
S3��M lb:'INNER CASING OR.TUBING eothermal dSK
2.Well Construction Permit#: ,.•C] FROM TO DIAMETER THICKNESSMATFRIAL
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.) fi- ft in.
3.Well Use(check well use): ft ft. in.
-
Water Supply Well: 17.SCREEN',:-:. .:<. `:,-. :;: ..
FROM. TO DIAMETER SLOT SIZE TATCKN.ESS MATERIAL
AgiicuIWral DMunicipal/Public ft ft in.
il Geothermal(Heating/Cooling Supply) JpResidential Water Supply(single) ft ft
I Industrial/Commercial E3Residential Water Supply(shared) -
:2I8:GRODT.''. _
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 Q Groundwater Remediation
,:19:SAND/GRAVEL-PACI{if a'Iicible
'Aquifer Storage and Recovery O Salinity Barrier FROM TO MATERIAL 'EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft
Experimental Technology D Subsidence Control ft ft
Geothermal(Closed Loop) OTracer 20.DRIIZ NG.LOG'(attidi`additidn'sI ib&djfiieces's-
i Geothermal(Heating/Cooling Return) M Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock p e in sire,etc.)
11nn /i ft. ft
4.Date Wells)Completed:l`laq .Z1 Well ID# 2bV ft sUft
lbr-at
5a.Well Location: Soft 0 ft
406 ft ft.
Facility/Owner .a Facility ID#(if applicable) [[��++ ft /ti('5t
O ZA
ft ft
i
Physical Address,City,and Zip ft. ft
21:REMARKS"•.":::;'1;: ::.
County Parcel Identification No.(PIN)
1;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwel�l field,o1nelalat/long is sufficient) 22.Cer' ation:
6.Is(are)the wells)JJPermanent or MTemporary Si a e ofA rtifed Well Contractor Date
By signing1hjk form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or Jallo with 15.4 NtAC 01C.0100 or 15A VCAC!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 ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
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: 24 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdilferent(example-
33 00'and 2@1001 construction to the following:
(
10.Static water level below top of casing: `IC) (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 Iniection Wells: In addition to sending the form to the address in 24a
.Well construction method: O Y
above,also submit one copy of this I'form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) J construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
- k
13a.Yield(gpm) 10 Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
�j the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection typef Amount: O CZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016