GW1-2022-03127_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: !
1.Well Contractor Information:
mil lV(� ! ko ra d •14:.WATER ZONES,,'. -
We1lContractor Name FROM TO DESCRIPTION
13s- q /� ft ,ft. � ,
ft ft :
NC Well Contractor Certification Number 15:OUZ7 R-eASD 1G,(fo"r multi=rased wells 02 LII�ER (irk?cahle)'
Morgan Well &Pump, Inc. FROM I TO' DIAMETER THICKNESS MATERLL
+1 f19qt. 61/8/ In' sd21 pvc
Company Name
` (�t Q� 16`II�II�R C 4SING OR T JBING: eutliermal cIo'sed rod .' "'' '
2.Well Construction Permit#: G & l FROM TO DIAMETER THICHIVESS MATERIAL
List all applicable well constructionpermils'(1.e.UIC,t.'Owgy,State,Ymiance,etc.)- ft ft in.
t
3.Well Use(check well use):
ft ft. in.
Water Supply Well: M'SCREEN', •'.. `_:. .`•w:. ,,:.:. :.::.::._�.- :=.' .
FROM TO DIAMETER SLOT SIZE THiCKTILSS MATERIAL.
01nduAgricultural QM • pal/Publ1c ft ft in.
strial/Commercial
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft J Residential Water Supply(shared) ;.Y8:GROUT::. :; "'•=":Irrigation FROM TO MATERIAL EMPI&CEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
'Monitoring DRecovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge rij Groundwater Remediation r -
:19:SAND/GRAVEL'PA (if a liciblB
'Aquifer Storage and Recovery DSalinity Bamier -FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test Ostormwater Drainage- ft ft.
i Experimental Technology ©j(Subsidence Control ft ft
i Geothermal(Closed Loop) Tracer :20.DRUUNG.LOG-atticli=addition-slslieetsifi ecessa a. --
7'
t Geothermal(Heating/Cooling Return) J Other(explain under#21 Remazks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain s ze eta)
tfqd4.Date Well(s)Completed: - Well ID# ft ovn5a.Well Location: l68 tt' f I
,Davit i� Tall�t�- ft ft
Facility/ vnerN//a��me Facility ID#(ifapplicable) ft ft
Ay-Az.�i is Chnce- de.Le,AL- ft ft-
Physical Address,City,and Zip ft ft
1•/� ubj/X'�� �21iRF'MhRF.'C'.:.,.
County Parcel Identification No.(PIN) `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: +' - 1
(ifwell field,one lat/long is sufficient) 22. �• raGv`i`valiti+ i'Y'•, +✓iJ "V
41944101 N �` l,�tba°7S31 W
6.Is(are)the well(s) ermanent or OTemporary Signature of Certifie ell Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or EffNo with ISA NCAC 02C.0100 or 15A NCAC 01C-.0200 Well Construction&andmdr and that a
Ijthis is a repair,fill out known well construction information and explain the nature of the ropy ofrhis record has been provided to the Well axuer.
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 surfacer (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths##'different(example-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: Lio (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in.) 24b.For Injection 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 r LL construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
FOR WATER SUFFIX WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) J-5 Method of test' air pressure 24c.For Water SunpIy&Iniection Wells: In addition to sending the form to
�s the address(es) 'above, also submit one copy of this form within 30 days of
13b.'Disinfection type: iC-4,il Amount: DU? 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 Revised 2 22-2016