GW1-2022-01731_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contr ctor Infformpatiioon:: r l
14:.WATER ZONES _ .. . .:. ..
Well Co to �ae FROM 0 DESCRIPTION
p ,� 6 ft ft.
ft ft
NC Well Contractor Certification Number 15;OUTER CASING•for multi-Eased wells OR LIlYER(if'a"livable'
Morgan Well & Pump, Inc. FROM ro DIAMETER TmcxlvEss MATERIAL
+1 ft. q6 ft. 6 1/81 in. sd,21 pvc
Company Name
� 16:HVNZJR CANING OR TUBING'•eothe-rmal�clo'sed loo' ;.
2.Well Construction Permit#: L l FROM TO DIAMETER THICHNESS MATERIAL
List all applicable well construction permits'f.e.WC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
CREE
Water Supply Well: oM To DIAMETER SLOT ST2 E' THICKNESSf �MATERTAL
Agricultural QMunicipa/Public ft ft
J Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft
I Industrial/Commercial DResidential Water Supply(shared)
:18:GROUT..'-.- .:, >.:•.:...:. :.....
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 40 ft' bentonite poured
Monitoring Recovery ft. ft
Injection Well:
ft ft
_.)Aquifer Recharge r Cn-oundwater Remediation
�,�, 19:SAND/GRAVEL'PACK if a •livable
Aquifer Storage and Recovery �YSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
Geotherinal(Closed Loop) OTracet :20.DRILLING.IOG'(attacli'sddition'alsli'eetsifriecess ")':'::
Geothermal(Heating/Cooling Return) M Other(explain under#21 Remarks) FROM To DESCRIPTION ccalor,havrdness,soil/rock ty e rain size,etc.)
/► U ft ft 'J�f�7
4.Date Well(s)Completed: —�' t+� Well ID# ft ft fow^ W.
CIIA-
5a.We Location: G�6 ft p ft. ��/
Facility/Owner Name ))Facility ID#(if applicable)
ft ft
'3 "`1 S�6ne,� /`t(/�G 1�� �i�e��'EM ft ft
Physical Address,City,and Zip ft, ft
23���/
L,n ed l 21:REMARxs
County Parcel Identification No.(PIN) 02'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one llaat/loong is sufficient) 22.Certification: {'
3J' 1- ` 77 N V Q 1,lU//2SD W 7Gn�t 'Lc�21
6.Is(are)the well(s)APermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: rJ1 Yes or SLNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthii record has been provided to the well owner.
repair under#11 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
V 9.Total well depth below land surface: ZQ (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 e@200'and 2@100) constriction to the following:
10.Static water level below top of casing: ! d (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
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: O Y LI construction to the following:
(Le.auger,rotary, 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) v Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4-J«✓ Amount: completion of well construction to the county health department of the county
r—
where constructed.
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016