GW1-2022-03076_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I' '
I.Well Contractor
,,Innformation:
N 16 avl 1,14.WATER ZONES 'i'.
Well Contractor Name FROM I TO DESCRIPTION '
a 2 D It Z6o ft'72--A ft ft.
NC Well Contractor Certification Number '
15:OUTER,CASING,for mNti=cased"wells)O#£I:IlgEI2(if a'licalile)':1:=::`'-::'•.`
Morgan Well &Pump, Inc. FROM TO' I DIAMETER I THICMgESs I MATERIAL
Company Name
+1 ft ft 1 61/8/ in• sdr21 pvc
,- •
16:1NNER CASING OR-TUBING eotliermal•c1o'sed-rod' '' '
2.Well Construction Permit iv: 18613 FROM To DIAMETER TffiCKNESS r..MATERIAL,
List all applicable well construction permits'(ie.WC,County,State,Ym-iancA etc.)- ft ft m•
3.Well Use(check well use): ft .t• in.
Water Supply Well: 17--SCREEN ::r::. .` :::. (•.. :j. r:r.:,• •:`
FROM TO fDtAM7=R. SLOT SIZE T3TCKNESS MATERTAL .
Agricultural QMunicipal/Public ft, ft, ,
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft
i Industrial/Commercial Residential Water Supply(shared) ;;18:GROUT-.'--.- •' `': ;: -
E Irrigation FROM TO MATERL4L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft bentonite poured
:Monitoring DRecovery ft. ft.
Injection Well:
ft ft.
_J Aquifer Recharge []Groundwater Remediation :19:SAM/GRAVEL PACK d a"liable '. "' " ` ' '
Aquifer Storage and Recovery DSalinityBarrier I FROM TO • MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft ft
i Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) [](Tracer :20.DRILLING.LOG"(attfiEE-dditidii0 sheet-tf i ecess 'j::s'
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,eta)
(3 .M ISO ft' I A96 K a.
4.Date Wells)Completed:_ Well TD# 3 ft �� ft- e�Jlti '1 bKb
San.Well Location: �.ft ft CA V%LK G i,.
ft ft V` 'T�
Facility/Owner Name ---, r Facility ID#(ifp
a/plicable) ft ft
316 n k l 'J�a A-1. �e4 •b e' /v� ft ft. . ll —Ay
Physical Address,City,and Zip ft ft —
�jaS'f'o✓1 �YO,-(y` `21:RY;IkAuuc° - - -- -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —_
frf well field,one lat/long is sufficient) 22.C cation r`'�`E'� I is 1 ' ')`'1"`y`Y, I
35. 397,528 -N —81. 7S9 W
6.Is(are)the well(s)&Vermanent or OTemporary Signature of C Well Contractor Date
By sip ung this fo ,I hereby certify thaf'the wells) was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or � with ISA NCAC 02C.0100 or ISA NCAC 02C..0200 Well Construction Standm-ds and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofihe copy ofthii 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd8erent(example-3 a 00'nrd 2@100D 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.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 0 r L� above, also submit one copy of this form within 30 days of completion of well
t construction to the following:
(ie..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 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 type:CjfAXuja4U Amount: completion of well construction to th'e county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Envirorunental Quality-Division of Water Resources Revised 2 22-2016