GW1-2022-03110_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W�AContractor information: �
��C�,rL�� ��•q��= '14:.WATER ZONES;'. - i_ -
Well Contractor Name FROM TO I DESCRIPTION
- it. ft
NC Well Contractor Certification Number '15:OU2'E•R,12ASING,for tnniti=cased wells OR LINER if a-'lirahle
Morgan Well&Pump, Inc. FROM TO DIAMETER THICKNESS MATF.RTd7.
Company Name +1 ft. It. 1 61/8/ in. sd,21 pvc
FROM ER CASII�TG OR TIIBIAM eothermal closed FS ='_'
2.Well Construction Permit#:--7�, {-rV FROM TO DIAMETER TffiCKNFSS .� MATERIAL
List all applicable well construction perm iti rz.e.UIC,County,State,Vw-iance,etc.)- ft ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17_SCREEN'•:,:. .:. _:.:.:.:: :�: ',.:'r.::=:•,t..-� :..:. ..:'.
VROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL.
Agricultural [3Muaicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
I Industrial/Commercial l3Residential Water Supply(shared) 18-GROUT-.'--.`
b I1Ti ation FROM TO MATERIAL - EMPL.ACEMENT METHOD'&AMOUNT
Non-Water Supply Well: 0 ft 20 ft.
bentonite poured
Monitoring Recovery ft. ft
Injection Well: M ft
__I Aquifer Recharge Groundwater Remediation r.
Aquifer Storage and Recovery :19:SAND/GRAVEL-PA.CK if ii 'licible
Q g ry OSalimtyBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QlStormwater Drainage ft ft
Experimental Technology Subsidence Control ft ft
i Geothermal(Closed Loop) OTracer :20.DR1LLING.LOG'(ittic6`addition'sl slieets,ifaieess''j-{'
FROM TO DESCRIP ION(color,hardness,saillrock type, in size,etcft. ` '
1 Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) , ft
_. ..
4.Date Well(s)Completed '✓�� Well ID# / ft J ft. NV 1,
5a. 11Location: ft ft
•� ft #I f
lt
Facili /O erNamee.� Faciliit^ty M#(ifapplicable) m ft 6�ft
&A Gulq ft. ✓1. (wi
Physical�ddress,City,and Zip �6� ft. ft. � ""
n O ( 21:I2EMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifgell field one lat/long is sufficient) k.t.,
,/,1� �/ 22.Certification: �„d±! .:�j�"1''�
/Obi 0 l W " f('
N
// //�� N'. iirV
6.Is(are)the well(s)oPermanent or OTemporary Signaturd'6fCertrfied Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: M'Yes or nNo with 15A NCAC 02C.OI00 or ISA NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair fill out known well construction ififormation and explain the nature ofthe copy ofthii 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 if different(example-3@200 m 2(a)1001
construction to the following:
10.Static water level below top of casing: 0 6 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) t 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�LI above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �0
construction to the following:
(i.e.auger,rotary,cable,directpush,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 Sunnly&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: W1 Amount: 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 l Revised 2-22-2016