GW1-2022-01724_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W tractor Informatio :
14..WATER ZONES
Well ContractorFROM TO DESCR1PT10N
ame �
ft ft
ft ft l
C Well Contractor Certification Number 15:OUTER CASING,(frii mulfi-dared wells OR LII�TER if'a"'livable `.=:
Morgan Well &Pump, Inc. FROM o DIAMETER THICKNESS MATERIAL
+1 ft ft 61/8/ m' sdt21 pvc
Company Name 1 y :a;.'.
r� 16:INNER C' G OR TUBIl�TG'•eothe-rural closed-lod'
2.Well Construction Permit#: - I Vq' FROM TO DATER I THICxivEss I MATExrAL
List all applicable well constructionpermits'(.e.UIC,County,State,Variance,etc.)- ft ft in.
3.Well Use(check well use): ft fr. •
1 17.SCREEN',:<
Water Su ". . .' ..:'
PP Y Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
_=Agricultural QMunicipal/Public ft ft in.
i Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft. ft in.
Industrial/Commercial Water Supply(shared) .:
1&GROUT.':.' .:, >.``.: .." <.::."'
E Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. .bentonite poured
Monitoring [)Recovery ft ft.
Injection Well: ft fr.
3Aquifer Recharge Groundwater Remediation
:19:SAND/GRAVEL-PACK Cif a 'licatil8
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 20.DRILLING.LOG'(attach`addition'aI iheetsifnedes"s_ ;V`k' ' - _
TO DESCRIPTION(color,hardness,soil ck
I Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM f° a ft. /ro a in size etc.)
(( b �
4.Date Well(s)Completed:l L512- Well ID#
5 ll Location: ft ft
Ye, C C ft 36-(5 ft- b rt,.t' l
Facility/Owner Ii—e�/�� ([/��,� Facility M#(if applicable) ft ft
l6slf lb'4Ky y VC l.�✓b� I' ft ft
.o� ,is
P srcal Ad � ft ft
Address,City,and Zip
PA Ia�YU�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. tification:
55i 5a)-6 N —ou. �� 1 W
� gSiii1ftre $'Certified Well Contractor 6.Is(are)the well(s)oPermanent or Temporaryni hisform,I her•ebv cer4 that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well• ©'Yes or J@No 5A CAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair•,fill out known well construction information 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 of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3l JLJ (ft-) 24a. For All Wells: Submit this form within 30 days-of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: (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 Iniection Wells: In addition to sending the form to the address in 24a
�—/`� l above,also submit one copy of this form within 30 days of completion of well
r
12.Well construction method: 1 0 1 "`Ir LI construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Injection 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 typ Amount: J��d— 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