GW1-2022-01738_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.WelkContractcT infai-rAttm:
14:.WATF.R ZONES-,'. -
FROM TO DESCRIPTION
Well Contractor Nkne ft. ft.
7 .i
ft. ft i
NC Well Contactor Certification Number 15:OU. CASING,(foc multi=rased wells)QR LAVER(if a'livable
Morgan Well &Pump, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. ft. 61/81 in. sd21 pvc
Company Name '�Q ICL4NER C' G OB T JB]NG ebthermal dosed lod' r' :<:: '
2.Well Construction Permit#:�6a . %-1 FROM To DIAMETER to THICKNESS MATERIAL
List all applicable well construction permits(t ,e.WC, om ,State,Variance,etc.) fr' fr'
ft. fr. in.
3.Well Use(check well use):
I SCREEN'.:,:..<. `_:. . `:.:.:.:"::..0 :::_ _:,:::.::- !..';.:.. .::'• '
Water Supply Well: 7TO DIAMETER SLOT SLZE THICKNESS MATERIAL
'Agr'icultural �Municipal/Public ft in.
I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft in.
i Industrial/Commercial OResidential Water Supply(shared) ::18:GROUT. ':.'.':::
FROM TO MATERIAL :: EMPLACEMENT METHOD&AMOUNT
Ini ati0n
Non-Water Supply Well: 0 ft 20 ft. bentonite poured
Monitoring DRecovery ft. ft.
Injection Well: —ft. ft.
__I Aquifer Recharge L_i Groundwater Remediation
O
�^,� -19: ACK SAND/GRAVELT if a"licabl'e "'
Aquifer Storage and Recovery Salinity Bamer FROM TO MATERIAL EMPLACEMENT METHOD
ni Aquifer Test [3Stormwater Drainage ft. ft
_i Experimental Technology Subsidence Control ft.
Geothermal(Closed Loop) Tracer 20.DRTLLLRVG.LOG'attaBcti'addition'slslieetsifiiecess
FROM TO DESCRIPTION(color,hardness,soil/rock grain size,etc.
Geothermal(Heating/Cooling Return) 1 Other(explain under#21 Remarks) ft ft.
n - a
nirA A,
4.Date Well(s)Completed: u � �'' Well ID# ft
ft. 5 ft.
5a Well Location:
Facility/Ow rr Name Facility ID#(if applicable) ft ft
v ft.
cal Address,City,and Zip
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Q
(if well field,one lat/long is sufficient) 22.Certification:
3 q3 N -gb.5�733 W �Z
6.Is(are)the well(s)IMPermanent or QlTemporary
r,ig.i-g1i:`fbrm,
rtified Well Contractor Date
I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or ONNo with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction iriformation 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: ! (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1fdiierent(example-3@2200'and 2Qa 100) construction to the following:
10.Static water level below top of casing: ��+ (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino 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: �—/�1 "'Y L� construction to the following:
(Le.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 Water SuppIy&Injection Wells:Wells: In addition to sending the form to
o. the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection typ : m D Amount: 1067- 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