GW1-2022-01722_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD (GW I) For Internal Use Only: ft1`lurv ! .
1.WeII_S;pgiractor Info�n: .
J14:.WATER ZONES--,', :: :. ..
Well C(onntrac or e - FROM TO DESCRIPTION
"C A ft ft.
NC Well Contractor Certification Number ft ft
l 15:OTJTEIZ C9SiNG,(foc mnIti=(ised wells)OR L]lYElt(if a'licahle' :";Morgan Well &Pump, Inc. FROM TO .:
' DIAMETER THICKNESS MATERIAL
Company Name +1 ft 11, 6i/81 in. sdr2i pvc
✓ C 16 nVNEI2 CASING OR TDBIXG. 'eotfiermal'cIo'sed lod` -
2.Well Construction Permit#. ���+++ FROM TO DLSMEPER THICKNESs MATERIAL
List all applicable well constt ucticn permits r.e.UIC,Couruv,State,Ymiance,etc) ft. ft in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well:
._Ag1lCnitllral ni Municipal/Public FROM TO -,. DIAMETER. SLOT SIZE THICKNESS KMATERTAL.
ft. ft. in.
i Geothermal(Heating/Cooling Supply) 1PResideatial Water Supply(single)
ft ft in.
I Industnal/Commerc[al aResidential Water Supply(Shared)
:18:GROIIT.
Int FROM TO ••.'.,MATERTAL �- EMPLACEM TNT METHOD&AMOUNT
e Non--Waater Supply Well: o ft zo ft
bentonite poured
'•Monitoring Recovery Injection Well: ft ft
Aquifer Recharge DGroundwaterRemediation ft ft.
Aquifer Storage and Recovery D Salinity Barrier �'S TD/GRAVEL PACK if lickble ".
FROM TO L !'EVffLACEMENT METHOD ..Aquifer Test [3stormwater Drainage ft g,
I Experimental Technology DSubsidence Control ft
ft.
Geothermal(Closed Loop) Tracer DRIILIIVG.TOG'(kttadi'idditidn'al sheet' necesss
FROM TO _).• '
Geothermal(Heating/Cooling .e�turm) �jJ Other(explazn under#21 Remazks) ESCtRhIPTION(w1or,hard us,sail/rock type e in Size,ere)
I Lw �jl� 0 ft ,,L5 ft.
w _
4.Date Well(s)Completed: Well M# ;)js ft p ft.
raw l u le
�5 Well Location: `_' �� ft �lI_�g, �1U �� �. •
�wo � 1N ��� ft !+� ft l
Facility/O��.e
Facility M#(if applicable) ft ft
(Gcr-s Ck Avetc6tir c zt6?.5 ft ft
Ph ical Address,Cily,and Zip J ft ft
axe :-
��r
County Parcel Identification No.(PIN) ;1 027:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latlong is sufficient)
22.CertificafCe�tifiedWtionellContractor ;.•',.
35. 2g�9 N -�o, �3Z`d W
6.Is(are)the well(s)&Permanent or DlTemporary Si 1129 z.z
his Date
7.Is this a repair to an existing well: certify signing this form,I hereby cei thatithe wel ls) was(were)co nstructed in accordan ce
e ©Yes or �No with 15ANCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair ftll out known well construction biformation 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 bf wells construction details. You may also attach additional pages if necessary.
drilled:_
9.Total well depth below land surface: G�tO SU13MTTTAL INSTRUCTIONS
(ft)
For multiple'wells list all depths ifdiferent(example-3 a 00'and 2Q100) 24a. For All WelIS: Submit this form within 30 days of completion of well
•' ,� construction to the following:
10.Static water level below top of casing: �{
Ifwater level is above casing,use"+^ (ft) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter: 6 (in.)
24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method- �� �L� above, also submit One copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,directpusli,ere.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield co.) Method of test: air pressure 24c.For Water Supply&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�t_�6rY(^,{�Ti Amount: b 67 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