GW1-2022-01733_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
ontra t >,ra pon:
1a jdX�1,�Jy 14:.WATER ZONES
FROM TO DESCRIPTION
Well CouftuJ Name ft ft
ft ft
NC Well Contractor Certification Number 15;OUTER-CASING:for&ulti-cised wells OR LINER(if'a' licable-
Morgan Well &Pump, Inc. FROM TO DIAMETER THICIG`IEss MATERIAL.
+1 ft ft 61/8/ in' sd21 pvc
Company Name
16:'INNER CASING OR TIIBING'�ebthei=utal closed-loo r
2.Well Construction Permit#: FROM TO DIAMETERt TBICKNiS-S MATERIAL
List all applicable well construction permits(.e.WC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 1VSCREEN',:,.. ;:.a_._. .' :.:.:,:;.;_:.•, ::: ,;_",;..;,':::::<=.!.. ;.:..
PP y FROM TO DIAMETER SLOT SIZE TRICKNESS MATERIAL
_'Agricultural rilMunicipal/Public ft ft in. ;
i Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft
I Industrial/Commercial DResidential Water Supply(shared) GROUT.
•.Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
Monitoring ORecovery ft. ft.
Injection Well: ft ft
-.J Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL-PACK if a`licatile
L-TAquifer Storage and Recovery Salinity Barrier FROM To MATERIAL FrVIPLACE. T METHOD
Aquifer Test [3Stormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer :20.DRMJDNG.LOG'(attidi'additidn'al slieetsifrecess
Geothermal(Heating/Cooling Retum) -i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock ty e rain size etc.)
4.Date Well(s)Completed:VLl i 1�\ Well ID# ft LPJ ftbrajrx
5 .Well Itocation. ► j 5 ft G1 ft
ft 4ac� ft h
1
Facility/Owner Name Facility ID#(if applicable) �� ftfr
� L �t1�e�S� "C' ft ft,p
h sical ss,Ci and Zip ft. ft -
LA
County Parcel Identification No.(PIN) FEB 0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
N DS W 4,o -2�::>
6.Is(are)the well(s)SPermanent or 13Temporary
SigoaXNDC1,02C.0100
led Well Contractor Date
By si "m,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well• E]Yes or E!No withI or 15A NCAC 02C.0200 Well Construction Standm•ds and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under-421 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geo robe/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: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:32-0 ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(200'mrd 2@100) 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 Infection 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 O 9�/��N construction to the following:
(i:e.auger,rotary,cable,directpush,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 &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 typ Amount: B 0z completion of well construction to'the county health department of the county
MSIVW
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016