GW1-2022-03106_Well Construction - GW1_20220307

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
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1.Well Contractor Information:
M� P
•14:.WATERZONES:'. - � •?_�',,
Well Contractor Name FROM TO DESCRIPTION
J /Z 6 ', ft // ft
ft /® ft i
NC Well Contractor Certification Number 15:OUTER;CASING,(for tnNii-rased wells)OZ2 LII3ER if a'licable)' .:::':.:; •.
Morgan Well &Pump, Inc. FROM TO' DIAMETER THICHIVESS MArR.RTdx.
+1 ft 1 ft 61/S/ i in' sd21 pvc
Company Name 1
(r"- c� �j a/n, 16..'IlV1�It CASING OR.TUBII4G. •eotliermal•clo'sed-ltid L':."'-'-�' `•=%• ': -
2.Well Construction Permit#: w����� `V FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construcdonpermits'Cz.a.WC,County,State,Variance,etc)- M ft in.
3.Well Use(check well use): ft "`
17.-SCREEN.:-.: _ _ - ., ' ••"•-:'. .-
Water Supply Well: FROM TO DIAMETER ~ SLOT SIZE THICKNESS rtMATERIAL.II
Agricultural DMunicipaYPublic ft ft in.
Geothermal(Heating/Cooling Supply) DR41dential Water Supply(single) ft. ft in.
Industrial/Commercial E3Residenfial Water Supply(shared) -
GROUT-.'-. -
1 hri ation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft. bentonite poured
Monitoring DRecovery ft. ft.
Injection Well: ft ft
Aquifer Recharge [3Groundwater Remediation
-.79.'SAND/GRAVEL-PACK if ii `iicabl'e
I'Geothermal
Aquifer Storage and RecoverySalinity Barrier FROM TO - 'MATERIAL EMPLACEMENTMETHOD
Aquifer Test E3Stormwater Drainage ft ftExperimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :26.DRILLING.DOG'(hL t iE`additidnal'sheetsifaecess :{
P'eating Coolin Return FROM TO DESCRIPTION color,hardness,soiUrock e, ' in size,etr.
(Heating/Cooling�/ g ) J Other(explain under#21 Remarks) 07 ft 4re ft
4.Date Well(s)Completed: V Well ID# ft- �+ fL
52.Well Location: ft. &0 ft (JL.Vet A
I
ft ft
Facility/Owner Name Facility lD#(if applicable) ft ft
4\1 y t 64e, tom•. Ml CVIbA C
Physical Address,City,and Zip ft ft -
rr
4—>�1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/Seconds or decimal degrees: `
(if well field,one lat/long is sufficient) pL '
22.C catio
.54111I N --I].. (` w
�-23•-�
6.Is(are)the wells) Permanent or Oi Temporary Signa a of de red Well Contractor Date
By sio ping this orm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or J!J14 with ISA NCAC 02C.0100 or ISA MCA 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction itiformation and explain the nature ofthe copy ofthis record has beenprovided to the well owner.
repair under#2J remarks section or on the back of thisform.
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: 2—co (ft-) 24a. For All Wells: Submit this forul within 30 days of completion of well
For multiple wells list all depths if different(example-3 c@200'and 2Qa 100) construction to the following:
.10.Static water level below top
of casing: �JO (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
t.
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r Q LI construction to the following: i
(Le.auger,rotary,cable,directpush,eta)
Division of Water Resonrces;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,IRaleigh,NC 27699-1636
13a.Yield(gpm) y Method of test: air pressure 24c.For Water Supply&Iniection We11s: In addition to sending the form to
�t
the address(es) 'above, also submit one Icopy of this form within 30 days of
13b.Disinfection type:6MWU Amount: b oz 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 i Revised 2 22-2016