GW1-2022-03809_Well Construction - GW1_20220404

WELL CONSTRUCTION RECORD (GW-1), For Intemal Use Only:
1.Wo Contractor Information:
d •14:.vdATERzoNEs•:•.
Well Contrks a FROM TO DESCRIPTION
S. I �^ ft ft' I
�F1 ft ft I i
NC Well Contractor Certification Number
'15:OU�ER:C:ASING,(fo"r riiniti=risedw'elLs)ORI;Il�TE1L(if a'livable '
Morgan Well&Pump, Inc. FROM TO' DIAMETER THICKNESS MATERTAL
Company Name +1 ft. ft' 8 1. 118/ f im' sdr2l pvc
p y ��[�/7 1d:�Il�TNI;RC• GOR-TQSIlVG.' eotiiermalclb'sed hod`: `'_' ::
2.Well Construction Permit#: �1_ —1 FROM TO D THICKNESS �•,•MATERIAL +
Listallapplicable well constructionpermits'(:.e,UIC,County,State,Variance,era)- ft ft ;in.
3.Well Use(check well use): ft ft• :in.
1 .
W
ater Supply well: 17:SCREEN',,: :::. .'•�<.•. 1'.:.;:-rt:.• i :'.: ;..: :.Y:,;•-r„:r::.. .::.;
FROM TO DIAMETER' SLOTSTLE THICKNESS NiATERLIL
�Municipal/Public ft ftthermal(Heating/Cooling Supply) Residential Water Supply(single) ft ustrial/Commercial E3Residential Water Supply(shared)
;iYBrGROUT-.*
!liTi ation FROM TO MATERIAL l EMPLACEMENT METHOD&AMOUNT
Non-water Supply Well: 0 ft 20 ft benton!te poured
'Monitoring DRecovery ft. ft
IGeothermal
jection Well: ft ft
Aquifer Recharge [3Groundwater Remediation ::19:S2PlD/GRAVEL'PACK 1fa"Ticable Aquifer Storage and Recovery ®Salinity Barrier FROM TO - MATERIAL EMPLACEMENTMETHODAquifer Test OStormwater Drainage ft ft.
Experimental Technology Subsidence Control ft ftGeothermal(Closed Loop) !Tracer :(Heating/Cooling Return) -i Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,sail/rock type grain s ze eta)
i.
?, U ft. � ft
4.Date Well(s)Completed:` 1� � Well ID# Z0. ft ft
Well DftVmv ES ft ft
Facility/OwnuJame Facility ID#(if applicable) ft 2c+)C�,ft
�1�Q� �iSlryurC kwc.�l NC.2��38 ft ft i
ical Address,
City,and Zip A ft ft -
�GU- l V9,( 21:R nrauTrc` -ter.- .x.
County Parcel Identification No:(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient 9crl try ^ *`
) 22 cation:
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6.Is(are)the wells)J@Permanent or [!Temporary Sign a of rtU1ed Well ontractor 11)a�te
B going is arm,I herebv certify thatithe wells)was(were)constructed in accordance
7.Is this.a repair to an existing well: []Yes or MNo with ISA NCAC 02C.0100 or ISA NCAC 62C.0200 Well Construction Standards and that a
Ifthis is a repair f111 out known well construction 4iformation and explain the nature afthe copy ofthis record has been provided to the well ownek
repair under#21 remarks section or on the back of this form. e I
23.Site diagram or additional well details:
S.For Geeprobe)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 NDMBER'of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.TotaI well depth below land surface: Zdo (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For_mukiple wells list all depths if different(example-3@ 00'and 2@100) construction to the following:
10.Static water level below top of casing: �0 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For Iniectien Wells: In addition to sending the form to the address in 24a
f above,also submit one copy of thus form within 30 days of completion of well
12.Well construction method: LI I
(i.e.auger,rotary,cable,direct construction to the following:
pusI;etc.) l' i•
Division of Water Resources,Unllllderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC-27699-1636
13a.Yield(gpm) 10 - Method of test: air pressure 24c.For Water Sunnly&IniectionttWells: In addition to sending the form to
Q the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type ;�('lVl� Amount: (�oz completion of well construction to Hie county health deparhnent of the county
where Constructed
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016
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