GW1-2022-03805_Well Construction - GW1_20220404

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: !
1.lontractor Information: f
LIA 14:.WATER ZONES•t'.
Well Contr�act'or] ame FROM •TO DESCRIPTION r
ft ft. lI i 1
I �
NC Well Contractor Certification Number ft ft, +
'15;OUTER:EASING,(fo"r multi=rased',fvells)OR LZ R(if a"licalile)'1
Morgan Well&Pump, Inc. = FROM TO' DIAMETER I I THICE34ESS MATERIAL
Com an Name q +1 R ft- fi 1/8/ in sdr21 pvc
P Y L I�
16:IlMR CASING O73 TIIBTNG.' eothei?mal cIo'sed hod' j`::.. �' `''•
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well constructlonpernzits'(r.e.UIC,County State,Ymiance,eta)- ft. ft I; in:
3.Well Use(check well use): f, ft• rn
iladustrial/Commercial
ater Supply Well. IVSCREEN'. :.. `:,-. .`�; •._•_.:,=:.r:'rt:. � .,::-s..' :'i::,i�.. r.:. .:
FROM TO DIAMETER SLOT SIZE THICKNESS 14IATERIAL.
Agricultural �Municipal/Ptlblic ft ft in.
Geothermal(Heating/Cooliog Supply) oResidential Water Supply(Single) ft ft in.
E311esidential Water Supply(shared) GROUT%'.. .
rExperimental
tion FROM TO MATERIAL EMPLSCEMENTMETHOD&AMOUNT
ater Supply Well: 0 ft. 20 ft bentonite poured
oring []Recovery ft. ft.
n Well: ft fter Recharge �GroundwaterRemediation ;19:SAND/GRA MPA CIC if a `licalil8 er Storage and RecoveryISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
r Test 11Stormwater Drainage- ft ftmental Technology Subsidence Control ft ftrmaI(ClosedLoop)rmal(Iieating/CooIing Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type grain size etc)
'q A� 0 .ft ft.
4.Date Well(s)Completed ZO u-. Well ID# V5. R s f, i
Sa.Well Location: 15 ft ftbrbwr� ToLk— .
W l \- `-A� ft oo ft J 6
L�� ft ft.
I'
Facility/Owner Name acilityID#(ifappIicable) i '
ft. ft. I '
,^ r,�•=
Ph sicalAddress,City,and Zip �" R .,ft
ful—
County Parcel Identification No.(PIN)
tires•} A�n.-'t. 4,
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) Q /f Q 1�r�, r,�•, �. r°:+ �' I4
3�•��2Q •n. {��. �2$�f 22.cepfification. er7t`Litw�v:r�1P�r��s:�����:I�S•1�:1f11�1-
w j 3
2
6.Is(are)the wells)j§Permanent or J Temporary Sign o ed Well Contractor Da
By and s form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or INNo with 15ANCAC 02C.0100 or 15ANCAC 02C•.0200 FYell Construction Standards and that
Ifthis is a repair fill out known-well construction idformadon and explain the nature of the copy ofthir 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 NUM13ERbf wells construction details. You may also attach additional pages if necessary.
drilled: I.
SUBMITTAL INSTRUCTIONS
OD9.Total well depth below lansurface:d (R•) 24a. For All Wells: Submit this form within 30 days'of completion of well
For multiple wells list all depths i'di#erent(example-3@200'and 2@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.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition io'sending the form to the address in 24a
t above;also submit one copy of this fbim within 30 days of completion of well
12.Well construction method: O A Y LI construction to the following:
(l.e.auger,rotary,cable,direct push,etc.)
. 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 246.For Water Supply&Injection Wells: In addition to sending the form to
,^`` q o the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: I,I�YL Amount: LD OZ., completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources i' Revised 2 22-2016
i