GW1-2022-03064_Well Construction - GW1_20220307

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WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only: C
1.Well ontracto or atifo�: E
�v -14:.WATER ZONES :
Well ntractor a I FROM I TO I DESCRIPTION
ft ft
ft it
NC Well Contractor Certification Number
'15:OUPER:CASING,(foc multi=rased:wells)OA IMgE,R(if a'livable' :=:i'.
Morgan Well&Pump, Inc. FROM TO' DIA11gTER T>�crnvFss MA't•a'.Rrex.
Company Name +1 ft ft,
61/8/ p rn sdP11 pvc
i6.`DMM G OR TIIBII�G.' eotlierma7 c1o'sed rod' .'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS '..,MATERIAL,
List all applicable well construction permits'r.e.UIC,Countv,State,Variance,etc)- ft. ftin.
3.Well Use(check well use): ft ft in.
VAgiicultural
upply Well: 17_'SCREEN'.
FROM TO DIAMETER SLOT SrZE ••TIrCKNESS MATERIAL .
01 Municipal/Public ft ftrmal(Heating/Cooling Supply) Residential Water Supply(single) ft ftial/CommerciO E3Residential Wa.4 Supply(shared)
::18:GROUT::-''.:: _ '•:::. •.. --..:_•.-7• ..r:�•;:•,:••; -::•.
rAquifier
FROM TO •MATERLAL - EMPL.4CEMENTMETHOD&.9MOUNT
r Supply Well: 0 ft 20 ft
bentonite poured
g Recovery ft. ft.
ell:
ft ft
echargeJ CnoundwaterRemediation
SAND/GRAVEL'PA:CIC if a'livabletorage and Recovery Salinity BamerFROME MATa nTer. ENffLACEMENTMETHOD
est DStormwater Drainage �tTO
ft.t Experimental Technology Subsidence Control ft
Geothermal(Closed Loop) 1ITracer :ZO.DRILIIIVGS OG'(attacli addifion'al s'Uets,d
I Geothermal(Heating/CooEng Return) _I Other(explain snider#21 Remarks) FROM TO I DESCRIPTION(color,hardness,soil/rock typN grain size,etc)
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a ft 5
4.Date Well(s)Completed:` 2Z Well ID# 5 ft ft
Sa.Well Lo cati Qft. D ft.
Te WaVerPtM
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�Facility/Owner Name
�� Facility ID (ifappliic'able) r ft ft PC Fz
',
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Physical Address,City,and Zip � ft ft
County Parcel Identification No.(PIN) , � � n
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat11ong is sufficient) 22.Certification:
3q 55 N 26 4M W
6.Is(are)the well(s) Permanent or OTemporary rS'1i!.p'V'1r'n'GLs
ertified Well Contractor
Date Z Z
form,1 her-ebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or J@No with 15A NCAC 02C.0100 or 15A NCAC 02C..0200 Well Construction Standards and thava
1f this is a repair fill out known well construction information andexplain the nature ofthe copy ofthis record has been provided to the well owner.
repair under 4121 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: VlJ (ft) 24a For All Wells: .Submit this form within 30 days of completion of well
For multiple wells list all depths lfdierent(example-33@200'and 2@100) eonstructiosto the following:
10.Static water level below top of casing: JD (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
il.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: f-O" L� construction to the following:
(Le.auger,rotary,cable,direcfpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
As13a.Yield(gpm) - Method of test: air pressure 24c.For Water Sunnly&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit lone copy of this form within 30 days of
13b.Disinfection type. 1�ri Amount: completion of well construction to the county health department of the county
where constructed i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2 22-2016
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