GW1-2022-03171_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
1-Well Contractor Information:
1
14:.WATER ZONES
WellContrac rNaamme I FROM TO `DESCRIPTION
�� ft. I .
ft ft.
NC Well Contractor Certification Number
15:OUTER:CASIN(r,(foc malti=rased wells)OR L3NER
Morgan Well &Pump, Inc. : FROM TO DIAMETER THICIGIESS MATERIAL
Company Name +1 ft. ft. 6 1181 ( in• sdr21 pvc
n 16:TNNDRC GORTUBIIVG:' eottiermal'clo'sed lode
2.Well Construction Permit#: A/ FROM TO DIAMETER THICKNESS
939 MATERIAL
List all applicable well construction perm is(n.e.MC,Counv,state,Variance,etc.)• ft ft. in.
3.Well Use(check well use): fL fr. in.
VAgricullural
upply Well: 17.SCREEN'.:.:.:
FROM TO DIAMETER SLOT SrZE THICKNESS MATERIAL .
[JMunicipal/Public ft. ft. in.
rmal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft inial/Commercial Residential Water Supply(shaz'ed) F..,...,,._ .:. •..:.::.
GROUT-.'-.".:, .. :,...,:
E hri atiOn FROM TO E IEMPL4CEMENTMETHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft bentonite poured
Monitoring Recovery ft. ft.
Injection Well:
_J Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salmi Barrer 19•SAND/GRAVEL PACK tf a "livable ":.:_:_ ;:-':,'.. _•".r-:': =• :.`
�' i FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test 0stormwater'Drainage ft. ft
I_J'Geothermal
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer :20.DRU-IMiG.LOG'(attiEY dditidn'slsbeetsifrieees's•-)'t
(Heating/Cooling Return) i Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type :rain size,etc-) '
4.Date Well(s)CompletedlV- Well ID# g . ft
Sa.Well Location: ��( ft ft. L,�
trig.. •lL1�2 nt,M K ft ft `[`C
Facility/ caner Name Facility ED#(if applicable) ft. ft
BIZ_ ft. ft
P ical Address,City,and Zip ft. ft
21]MMIARKg
County Parcel Identification No.(PIN)
s:tiw'�':v 1lisn7
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
Q'
' n 22.Certification:
�S.Slbq N U . ! is D W /J
6.Is(are)the wells) Permanent or 3 Temporary Si, a fCertified Well Contractor Date 1t�
B erring this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or SNo with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standmds and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the,,ell 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 GWA is needed. Indicate TOTAL NUMBER bf wells construction details. You may also attach additional pages if necessary.
drilled: %
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For mul (ft) 24a. For All Wells: Submit this fotm within 30 days of completion of well
multiple'wells list all depths if different(example-3 tr 00'mid 2QI00� construction to the following:
10.Static water level below top of casing: LA S (ft-) Division of Water Resources Information Processing Unit;If water level is above casing,use e
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: ro �(A above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.)
construction to the following: j
Division of Water Resources,Underground Injection Control Program,
EDisinfection
UPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: air pressure 24c.For Water Sunuly&Iniection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
typ • Y Amount: a 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
'r .