GW1-2022-03803_Well Construction - GW1_20220404

P iTm F ro
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: !
1.Well Contractor Information:
i I _
-14:.WATER ZONES •: j,: ...•r :i`
Well Con rName I FROM I TO I
-DESCRIPTION
ft ft
A ft ft
NC Well Contractor Certification Number
15:OUTER,G%ASING,(fdr multi=rased Yiells)OR T"snit.R(if a'lic2hle)':,
Morgan Well&Pump, Inc. FROM TO' DIAMETERI THICE\MS MATMUAL
+1 ft �qr ft.
61/0/ I in sdr21 pvc
Company Name 4
3f ri 16.JNNER CASING OR•TIIBIIVG:"eotliermalclosedIoo`: r6
2.Well Construction Permit#: (QLJ L FROM TO DIAMETER THICKMS + MATERIAL t
List all applicable well construction permits rr.e.UIC,CouniR State,Variance,etc.)- ft ft
3.Well Use(check well use): ft ft. in.
Water Supply Well:
I4:SCREEN',:.:.. ':;. .`�.•'•.•_•_• :.:;'r.•.. :' •; ,. ".; r,.- =:
FROM TO DIAMETER' SLOT SIZE TmcKNESS MATERIAL-
_ Agricultural [Municipal/Public ft. ft in.;
PGeothermal(Heating/Cooling Supply) [!Residential Water Supply(single.)' ft ft in.
IndustriaUCommercial Residential Water Supply(shared) :18:GROUT•:, _ _; `='••
rNoZn-V�Vater
tion FROM TO MATERLSL EMPLACEMENTMETHOD&AMOUNT
Supply Well: o ft 20 ftbentonite poured
oring Recovery ft. ft
Injection Well:
ft ft.
Aqujfe-Recharge [Groundwater Remediation r.
Aquifer Storage and Recovery [Salim Barrier �'SAND/GRAVEL•PA:CK 1f a"licabl8 "'.•.' =•'` ;. _.' .. '
tS FROM TO MATERIAL EMPLA CEMENT 1y=OD'
Aquifer Test [Stormwater Drainage ft ft.
Ll
N
Experimental Technology [!Subsidence Control ft ft
Geothermal(Closed Loop) [!Tracer :ZO.tiRIILINGLOG'(attar}isddition'slsheets�fnecessa j":�7•'=i :-
Geothermal(Heating/Cooling Return) r—il Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock type,grain size,etc)
4.Date Well(s)Completed: l"l ZZ Well IN ft ft-
5a.Well Location: ' /� Q ft ft•
■V O i•� �Y�/ ,6 ft
Facility/Owner Name
�,.+ Q� Facility ED#(if applicable)
P{Jhps'aal�Add�dre�ss,City,and Zip A A G ft ft'
l Orf'Z •21:'RFMARTCC'- `:i _ :A ,'.�.'.a'�._ MI.9,
County Parcel Identification No.(PIN),
5b.Latitude,and longitude in degrees/minutes/seconds or decimal degrees: APH 4 2022
(if well field,one laQt/long is sufficient)
22. tiflcation
N W .rr �tiit�LY� ' � eB'N'Ll��+
6.Is(are)the well(s)SPermanent or ['Temporary Sign e o ertifie Well Contractor Date
By �Inng arm,I hereby certify that'the weII(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or *No wit r ISAN 02C.0100 or ISANCAC 02C,0200 Well Construction Standards and that a
If this is a repair fill out brown well construction hiformation and explain the nature ofthe copy ofthii 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 baving the same You may use the back of this page to provide additional well site details or well
constmction,only 1 GW-1 is needed. Indicate TOTAL NUhdBER'of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
�9.TotaI well depth below land surface: J (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(ewmple-3 a 00'mid 2Qo 1000 construction to the following:
10.Static water level below top of casing: �b (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method r L� above,also submit-one copy of this form within 30 days of completion of well
(i.e.auger,rota cable,direct push,etc.)'
tn construction to the following:
ry,
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Suy y&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one'copy of this foam within 30 days of
13b.Disinfection type:Cht D Amount: 1 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
I
• r I