GW1-2022-03168_Well Construction - GW1_20220307

WELL CONSTRUCTION.RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14:.WATER ZONES•:'. . : r : r.•... `. :r'•.,..'.':'...-•.:: ;.
Well Con¢actor Name FROM TO DESCRIPTION
t��1(15SSSy ` ft �b ft.
it. ft I
NC Well Contractor Certification Number
15:OUZLR;QASING,(foi multi=rasedwe�ls)OLtLIIQER ifa'livable':; •.
Morgan Well&Pump, Inc. FROM TO' DLAMETER THICKNESS MATERIAL
Company Name +1 ft , it. 61/8/ in' sdr2l pvc
66$13 ICINNER CASING OR TUBING: eotliermal do'sbd rod`r r6
2.Well Construction Permit#: FROM TO DLAMETER THICKNESS MATERIAL
List all applicable well construction permits'll e.VIC,COuntl;State,Variance,etc.)- ft. ft. ! in.
3.Well Use(check well use): ft ft. in.
WaterSupplyWell: 17.-SCREEN',. �.•' :.:::.;:,,: . 4.. .:- ,.: .;'=.:. r.- ::.. ..::
FROM TO DLAMETER SLOT SrZE THICKNESS MATERIAL .
_'.Agricultural r-JiMunicipal/Public ft ft in.
I Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft is
I Industrial/Commercial E3Residential Water Supply(shared) _
::18:GROUT.',.".*.' _ _:,•,,..: _.
[Experimental
tion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: 0 ft. 20 ft. bentonite poured
oring Recovery ft. ft.
n Well: ft. fter Recharge Groundwater Remediation .19.SAND/GRAVEL'P9 rfer Storage and Recovery �ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
er Test E]Stormwater Drainage- ft ft
imental Technology Subsidence Control ft ftermal(Closed Loop) OITracerrmal(Heating/Cooling Return) J Other(explain,under 421 Rem ) FROM TO DESCRIPTION(color,hardness,soiUrock type rain s u etc.)
U ft ft
4.Date Well(s)Completed: . Well ID# ft ft. � /
5a. ell Location: ft O ft' 0Kerr '
��v y / /�ke -z L % ft ft „x v4.
Facility/Owner Name Facility 6#(if applicable) ft. ft
ft. rp
Phys ddress,City,and Zip q ft. f
�V17 f�cy Z1-REMARYS -
County Parcel Identification No.(PIN) L ti-;`r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 5(? "r"'
(if ell old,one lat/long is sufficient) •�,
22.Certification:
OU -N , wAw��� � ?y
6.Is(are)the well(s)APermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or 9&No with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair fill out known well construction information andpxplain 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 bf wells construction details. You may also to
additional pages if necessary.
drilled: � SUBMITTAL INSTRUCTIONS
R�
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 ail depths ifdifferent(e eanple-3Q200'and 2@100D construction to the following:
10.Static water level below top of casing: V (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
246.For Infection Wells: In addition Ito sending the form to the address in 24a
�� L`
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Q'
construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) I - Method of test: air pressure 24c.For Water Supply&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: L✓ Amount: completion of well construction to the(county health department of the county
where constructed-
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ., II Revised 2 22-2016
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