GW1-2022-03807_Well Construction - GW1_20220404

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ontractor Information:
Iyl'1 Cla u S V 14:.Wi1TERZONES;'. r r .�:;...•r:.=:r':.'...;. :'..._:.c.
Well Con/tractor Name F olm TO DESCRIPTION
/� — ft e1 ft
NC Well Contractor Certification Number 15: (for multi=rased wells)0Rt T-II4 R(Ira-'linable)'
Morgan Well&Pump, Inc. FROM TO DLAMETERI Tmci\ss MaTEIuu
Company Name - +1 ft ft - 61/81 f m• sdr2l pvc
36�a3 I INNER ' G OB•TIIBIl�G''eothermal elo'sed loo" : >' t 6
2.Well Construction Permit#: FROM TO DIAMETER; THICKNESS MATERIAL
List all applicable well construction permits'ri.e.UIC,County,State,Valiance,etc.)- ft ft.
m'
' I �
3.Well Use(check well use): ft ft. In.
Water Supply Well:
FROM TO DIAMETER" SLOT SIZE .THrCKNESS TMATERIAt.
Agricultural �J"i Municipal/Public ft ft in.,
i Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
I Iudustrial/Commercial DResidential Water Supply(shared)
,:18:GROUT•:
'hit ation FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: a ft 20 ft bentanite poured
Monitoring DRecovery ft. ft.
Injection Well: ft ft
_,Aquifer Recharge r_JJ Groundwater Remediation'
,:19:SAND/GRr1VFS'PACK if a 'licalile ..::,. :`::'-..,._'':: •..'i '..'•.i': ::.
Aquifer Storage and Recovery t3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QlStormwater Drainage ft ft
Experimental Technology DSubsidence Control ft ft
Geothermal(Closed Loop) OTracer :ZO.DRIISIlQG.L'OG'(attacli°additional s7ieets}f recess"'): :•:'=s _
Geothermal eating Coolie Return) FROM TO DESCRIPTION( la,hardness,soilfrock type,grain size,'eta)
(H g/ g ) Other(explain under#21 Remarks) ft ft
4.Date Well ft.
Completed:J J�d� Well ID# S `(?.
YWellLocation: G (� ft �J ft 1
5
oSS tiS��tl n. 7 ft / U ft k— 4.,.
Facility/ weer Name Facility ID#(if applicable) , V ft ft
Cl
� Cj�'Aot ����I/� ft ft.
Phys'cal Address City,and Zip ft ft
0weos", 71
Coud6 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iffwell field, lat/lon�is sufficient) .
i �j I ng NS016 qqj 3 w 22.Certification:
i
6.Is(are)the well(s)jj Permanent or OTemporary Siena e.of Certified Well Contractor Date LAVV
kdl.!.
By signing thisform,I hereby cer•tr,fy that the wells)was(were)constructed in accordance
7.Is thus a repair to an existingwell: D'Yes or with I5.4 NCAC 02C.0I00 or I5A NCAC 02C..0200 Well Const action Standards and that a
Ifthis is a repair frll out)mown well construction information Are nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. r,F R p
V F
• 23.Site diagram or additional well eRF
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provid tion well site details or well
construction,only,I GW-1 is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach ad prigs gagg�sary.
drilled:
SUBMITTAL INSTRUCTIONS � .�•�� .
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this Ows"W i90f well
For multiple wells list all depths if different(exalnple-3(,200'mrd 2/1�00D construction to the following: "w
10.Static water level below top of casing: V (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing;use"+" 1617 Mail Service Cen ter;Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
` above,also submit one copy of this for Im within 30 days of completion of well
12.Well construction method: r LI construction to the following:
(Le,auger,rotary,cable,direetpuslr,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WE Division
1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c:For Water Supply&Iniection Wells: In addition to sending the form to
AAr� the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: d Amount: ��V y completion of well construction to the county health department of the county
where constructed
FormGW-1 North Carolina Department ofEnvimnmental Quality-Division ofWaterResources I Revised222-2016
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