GW1-2022-01726_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ontra�c`tor Information:
.14:.WATER ZONES --
ROM To DESCRIPTION
Well Coutrac Name
UC � ft ft
J o ft ft.
NC Well Contractor Certification Number
15;ou RCASINGW&multi=esea wah O LM if a'livable'
Morgan Well&Pump, Inc. FROM To DIAMETER THIc1{i�US MATERIAL.
+1 ft 6 ft. 61/81 in. sd21 pvc
Company Name .
�A/ / a r n.A �� ���/J�1� 16:TNNER CASING OR TQBIIVG'•eothe-r'mal eldsed-too'
2.Well Construction Permit#:YY a (V (' v! FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.), ft. ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: Fxo> TO I DIAMETER SLOT SIZE THICKNESS �MATERIAL
Agricultural �Municipal/Public ft ft in.
i Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) ft. ft in.
I Industrial/Commercial [3Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring DRecovery ft. ft
Injection Well:
ft ft.
_!Aquifer Recharge n Groundwater Remediation
19:SAND/GRAVEL'PACK U a 'li6bl8
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
73JAquifer Test [3Stormwater Drainage ft ft
:]Experimental Experimental Technology OSubsidence Control ft ft
J Geothermal(Closed Loop) Tracer 20.'DRILLING.LOG'(attiiY ddifidti'sl sUets.if iiecess �)-'.,
i Geothermal(Heating/Cooling Return) !Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock ty e, rain size,eta)
) / G ft. G ft ./`
I4.Date Well(s)Completed: '�!'ZZ Well ID# l O ft. p ft. O ko
5a. ell Location: f� Oft 0 ft S(,N J h
9 1 r CI�SO�� / ft too ft �i L�
Facility/Owner Name Facility ID#(if applicable) ' f t U ft' A
fL711 Y tOA�Cyr< � �r�� Mr1'd�/`- ft ft
Physical Address,City,and Zip ft ft
4�ti�►b �6 L 7 t 2 966-f6 21:REMARKS
[�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: , 2�2?
(if well field,one��ong is sufficient) � � 22.Certification:
S `/7/Y N b b W
6.Is(are)the well(s) ermanent or 13Temporary SfgoAta 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 O!No with ISA NCAC 02C.0100 or ISA NCAC 02C.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: - % of'/ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓( (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 200'aynd 2@100� construction to the following:
10.Static water level below top of casing: / Q (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casino 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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r 0 r L�
(i.e.auger,rotary,cable,directpush,etc.) 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
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
fr the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I (C-1 Ck I/ Amount: I ti 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