GW1-2022-03164_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Duly: sty
1. o :ontractor
/ V��
14:.WATER ZONES-:-. - �': .'i--�'.,.•r:.:�:r';....'. :'...-..:.
Well C0�1' � FROM I TO DESC I TION
ft ft
•. ft f
NC Well Contractor Certification Number ft t
'15;OU.TER:CASING,(fnc mold-cased weIls)0R-l tgER(ifs'licible-c;':::':'.::'•.
Morgan Well&Pump, Inc. : FROM T DIAMETER I THICKNESS MATMUAL
Company Name +1 ft '61 ft- s 1/8/ 1 d21 pvc
��\� 16.11VNER CASING OR-TUBING'i edthermsa*cISsM A&d'
2.Well Construction Permit#:�"V`—'j/) FROM TO DL4METER T•a10ENESS MATERIAL
List all applicable well constructionpermits'ri.e.UIC,County,State,Yaniance,etc) f, ft in.
3.Well Use(check well use): R ft in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THrCKNus MATERIAL .
Agricultural MMuaicipa.UPublic ft ft. in.
Geothermal(Heating/Cooliug Supply) Residential Water Supply(single) ft ft. in.
I Industrial/Commercial J3Residential Water Supply(shared)
rGeothermal
tionGROUT.:-. ' =' `: : :..::FROM TO EMPLACEMENTMETHOD& OUNT
afer Supply Well: ft 20 ft bentonite poured
oring Recovery ft. ftn Well: fter Rechaz-ge Groundwater Remediationer Storage and Recovery Salim Barrier '�:SAND/GRAVEL-PACK ff a'icibre tY FROM TO MATERIAL EMPLACEMENT METHOD
r Test 0stormwater Drainage ft. ft
mental Technology Subsidence Control ft ftrmal(Closed Loop) 1Tracer .I:OG'(attiiH-idditidliAlslieetsjffiece s"")rmal(Heating/Coolkm Return) -J Other FROM TO DESC PT ON(color,hardness,soiUrock type,grain size,etc)
t (explain under#21 Remarks) ft
4.Date Well(s)Completed:+ Well ID# ft ft � hdor
e Sa.Well Location`: �C • ft �� ft
ft- om- Yl V6 G
Facility/Owner Name M#(ifapplicable) ft ft
3S�{� ar aln • � .,,�11 N�- ft ft
sical Address,City,and Zip ft ft
�a 3�15 IN69 C5 -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in de.-rees/minutes/Seconds or decimal degrees: p ^ram
(ifwell field,one lat/long is sufficient) 'r\h'r91 4
�� N. ��� r.
•���t • ^ 22.Certification:
ix+ wtwiftthAC
� Z
1112z-
6.Is(are)the well(s)�Permanent or Temporary rtifie ell Contractor Dale
inform,1 hereby cerhJy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes orNo 02C.0100 or 75A NCAC 02C.0200 Well Construction Standen ds and that a
I'this is a repair fill out known well construction btformation and explain the natw•e 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 NUNMER of wells construction details. You may also attach additional pages if necessary.
drilled:—.' • i
SUBMITTAL,INSTRUCTIONS
9.Total well depth below land surface:�d For m (frt-) 24a. For All Wells: Submit this form within 30 days of completion of well
multiple'wells list all depths if different(example-3Q200'and 1Qa 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:�� Y[i�_ above,also submit one copy of this form within 30 days of completion of well
construction to the following: i
(n.e.auger,rotary,cable,direct push,etc.) g
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 Water Suppiv&Injection Wells&Injection Wells: In addition to sending the form to
� ,h1oY" I? az� the address(es) 'above, also submit one:copy of this form within 30 days of
13b.Disinfection 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 .I Revised 2 22 2016