GW1-2022-03129_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Yontractor Information:
T
ZONES,,'.
Well Contractor Name - TO DESCRIPTION
ft.
NC Well Contractor Certification Number '15;OU'ERCASDYG,(i6�multi-rased wells O,t MNER(if a'licable)' i> c
Morgan Well&Pump, Inc. FROM TO' DTArvrr.:• R THICIGVESS MATERIAL
Company Name +1 ft ft I 61181 m. sd21 pvc
O p\ I 16.-DINER CASING OR-TUBIN6.(•eotbei mar closed rod
2.Well Construction Permit#: ` lJ FROM TO DIAMETER THICKNESS ~MATERIAL
List all applicable well construction permits'r.e.UIC,County,State,variance,etc)- ft ft in.
3.Well Use(check well use): ft ft. in.
VI.d'u
Supply Well: 17_"SCREEN'.:-:. .: '::. .`�; •.:• .•;..: :; . ,. ;.. �:- .:
71Ia1 FROM TO DIAMETER -SLOT SIZE .THICKNESS MATERIAL .
OMunicipaMblic ft ft in.
mal(Heating/Cooling Supply) !Residential Water Supply(single) ft. ft
al/Commercial DResidential Water Supply(shared) ::18:GROUT::. -
1ni ation FROM TO MATERIAL - EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: 0 ft 20 ft. bentanite poured
Monitoring 'D`.Recovery ft. ft.
Injection We1I: ft ft
_Aquifer Recharge [3GroundwaterRemediation
Aquifer Storage and RecoverySalinity Barrier FROM SAND/GRAVEL'PA:CK if a `lickble
TO MATERLAL EMPLACEMENT METHOD
_!Aquifer Test E]Stormwater Drainage- ft ft.
i Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer :20.DRMUING.LOG'(ittiE5i dditidn'slslieetsifieces's- '`;t'== =s '-
I Geothermal(Heating/Cooling Coolie Return Other FROM TO DESCRIPTI N(color,hardness,soil/rock type,grain siu,etc-)
(H g/ g ) (explain under#21 Remarks)
cs ft IT4ft.
Pi b:i�
4.Date Wells Completed: `��'� Well ID# ft G�Q ft k
5a.Well Location- /� a ft LO f. 6
ft OJ ft Q(A
Facility/Owner Name Facility ED#(ifapplicable) � ft ft
QQ60 ft ft
Physical Address,City,
(and Zi_p�� ft ft v_
Lkl CA 21tI2EM9RKS` -
County VParcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: +� l�
(if eyed,oAe jatfj ngJs sufficient) �+ 22.Certification
14 t
6.Ls(are)the well(s)aPermanent or [!Temporary S i re of Certified Well Contactor 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: ;Yes or nNo with ISANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofthis 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 if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: "�V (ft) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Qa 100� construction to the following:
10.Static water level below top of casing: / (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.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method �0.��L( above, also submit one copy of this Morn within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: air pressure 24c.For Water Supply&Iniectio111 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: %Ak< Amount: V completion of well construction to the county health department of the county
where constructed. j
I
Form GW-I North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016