GW1-2022-03061_Well Construction - GW1_20220307

ELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: :tiPFl1?
MINES
W
1.WeaLcautractor �o�
O 14:.WATER ZONES
Well ontra a FROM TO DESCRIPTION
ft
f
ft ft
NC Well Contractor Certification Number i
15:OU7 ER:CASING,(foc multi='6 sea wgM)OR TI ER(if a
Morgan Well &Pump, Inc. FROM TO' 1 DIAMETER TEEICIOESS MATERIAi
Company Name
+1 ft, ft- 61/6/ in' sdM pvc
16:INNER G OR'TUBII�G.' eother�alclo'sed-loo' - -
2.Well Construction Permit#: FROM I TO DIAMETER TMCRIVFSS 11 MATERIAL
List all applicable well construction permits' e.UIC,County,State,Variance,eta), ft. ft in.
3.Well Use(check well use): ft. ft in.
VAglicultural
upply Well: 11:SCREEN'.:,:. .
FROM TO r DIAMETER SLOT SIZE ••TrfrCKNESS RMATERiAL
DMunicipal/Public ft. ft in.
rmal(Heating/Cooliug Supply) Residential Water Supply(single) ft ftiaUCommercial Residential Water Supply(shared) :r18:GROUT:
I1Ti ation FROM TO - n MATERIAL - EMPLACEMENT METHOD'&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft.
bentonite poured
Monitoring DRecovery ft. ft
Injection Well:
�—,� ft
_I Aquifer Recharge L 11 Groundwater Remediation ft
Barrier FROM TO MATERIAL EMPLA
•.19:SA1�TD/GRAVEI,'PACK>f a'•licaFile ...:�: _�.:::._•• •.- - -'.�•: � .
'Aquifer Storage and Recovery DSalinity BaCEMENT METHOD
Aquifer Test 03tormwater Drainage ft ft
i Experimental Technology 0Subsidence Control ft ft.
Geothermal(Closed Loop) OITracer :20.'DRU-d2'G.LOG'('attacli'additidn'al sUets
G jf aecess ='•:'= _
eothermal(Heating/Cooling Return) I Other(explain under#21 Remarks) FROM TO DESCRIPTION(mlor,hardness,soil/rock type; in size,etc)
0ft. D ft.
4.Date Well(s)Completed-"�l Well ID# ft
e11 Locati
ft ft >(
ft ft
.FFaacilittyy/Ownner�Name
�/� Facility
yIEV(if a_ppli-bl.) ft ft
`�+�t nr�f-�Y•- �i�r�F-M .fit{ �7 f V���� ft ft .
Physical Address,City,and Zip ft ft
W'V' -21bI2Ei4IAR%S'.�::�.,;:--";.:..- ,• .:•..:,,:.. ,.
County W Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one llat/long is sufficient) 22.Certification' r+�.� 2M I rOM
N CJLJ• ]�V RI
r..l i.:.vrYdll tt.:�i I:VJt•�'" l•/�Z
6.Is(are)the well(s)IbPermanent or E3Temporary r Certified e- Contractor DAe f/—
By sio '» this form,I hereby cerfify that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or�No wi h 1 CAC 02C.0100 or)SA NCAC!01C,0200 Well Consruction Standards and that a
Ifthls is a repair fill out known well construction information and explain the natw•e ofthe copy of thii 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 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-I is needed. Indicate TOTAL NUM8ER'of wells construction details. You may also attach additional pages if necessary.
drilled: y
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 ifdifferent(example-3@200'and 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 casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
lI.Borehole diameter: 6 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r 0_1� above, also submit one copy of this;form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
F13b.Disinfectiontyperk("OSCA
ATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
d(gpm) J - Method of test: air pressure 24c.For'Water Sunply&Infection Wells: In addition to sending the form to
+ the address(es) 'above, also submit one copy of this form within 30 days of
Amount:_ �j d"r' completion of well construction to the county health department of the county
where constructed. E
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016