GW1-2022-01730_Well Construction - GW1_20220207

WV_LL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
.14:.WATERZONES
Well FROM I TO DESCRIPTION
ft C00 ft
ft ft.
NC Well Contractor Certification Number
15:OUTER,CASWG,(fdi'multi-rasea w6lls OR-LUJER(itaf3
Morgan Well&Pump, Inc. FROM I TO' I DIAMETER THIC1 LESS MATR.RTd7.
Company Name /// +1 ft ft. 611/ in' sd,21 pvc
!' ��_0 ���,' 16:7NNER CASING OR TUBING.''eotlierma7 cla'sed lou .' �'
2.Well Construction Permit#:_ L r Vy FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits'ri.e.LAIC,Cowuv,State,Variance,etc.)• ft• ft in.
3.Well Use(check well use): £t ft, in.
Water Supply Well: 17-'SCREEN',:- :<. w.•'.:t_.:.:.:.::'. :...:- ',,: ,:'.:::t.. -' :;'.. -:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural []Municipal/Public ft. ft
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft ft
I Industrial/Commercial []Residential Water Supply(shared) ;18r GROUf.'t." = ''•.hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft
bentonite poured
Monitoring []Recovery ft. ft.
Injection Well:
ft ft
J Aquifer Recharge []Groundwater Remediation
•19.SAND/GRAVEL'PA. if a�hmbli .
'Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL ..EMPLACEMENT'METHOD
Aquifer Test OStormwater Drainage % ft
Experimental Technology []Subsidence Control ft ft
Geothermal(Closed Loop) []Tracer :ZO.tiRII�LIlIG.I OG'(attadi'addition'al s3eetsjf fiecess"' =,.
Geothermal FROM TO DESCRIPTION(color,hardness,soil/rock type rain size,eta)
(Heating/Cooling Return) J Other(explain under#21 Remarks) ft ft.
4.Date Well(s)Completed: Y Well ID# ft "pyw fa/
Sa.R11Locaflon: ,I �ta f, 7� ft Sty'
�.Y IV ez / 7S ft (Jft 911�;
Facility/Ow r Name Facility ID#(if applicable) / a 60J ft- k— gr41.
4./ ?7- E ir�JT(L h pit PJ� C�If 1�fJ11► 6Vv ft L V ft. W,'k1
Physical Address,City,and Zip ft ft.
l �n cCIh
21:RE714ARKS'�
i
County Parcel Identification No.(PIN)
FED U
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `
(if II `d, e lat/long is sufficient) 22.Certification:
j- 7C N --g�-373 w y/ -
6.Is(are)the well(s) ,permanent or OTemporary Si ature of-Certified Well Contract Date
�{ By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
Cat
7.Is this a repair to an existing well: Yes or Own with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
Ijthis is a re fill out known well construction it formation and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarkr 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: V (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'mid QI00D construction to the following:
10.Static water level below top of casing: OV (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 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: L` construction to the following:
(Le.auger,rotary,cable,direct pusl-,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) 1 - 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 type: (Clil L)&f Amount: q/ 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 I. Revised 2-22-2016