GW1-2022-03810_Well Construction - GW1_20220404

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Contractor Information: ,
h.� 14.X&TZR ZONES a•. ':: .r :I.1...•r:. :.,..
Well Contractor Name FROM TOQ,
_ 35'77. ft. DESCRIPTION
��b �
NC Well Contractor Certification Number
I
15:0U7ER:CAS]NG',(f0'r mnlfi=rased wells)OR L•IlYER(if a'licable)',,:�::`:•::'•.'.:
Morgan Well&Pump, Inc. : FROM TO" DIAMETER; I THICKNESS MATERIAL
Company Name / +1 ft, g ft, 61/e/ I, ;in, sd,21 pvc
�,hb�J J 16:Il�Il�R CASING OR•TUBII�IG.'•etitfiermalcIo'si:d-lod' :. ``"" ••' `
2.Well Construction Permit#: FROM TO DIADSL+TER THICKNESS j.,MATERLIL
List all applicable well construcfionpermits'ri.e.UIC,County,State,Variance,etc)- ft fit { in.
3.Well Use(check well use): ,
ft ft. in.
. 17_-SCREEDI',:r:: :_ ... -.. . ; +-_ ..-._;-�7,-__•.. .: :
Water Supply Well: VROM TO DIAMETER I-SLOT SIZE I TMCFU—S JillrWATER7AL.
Agricultural �M cipal/Public ft. ft in.i
Geothermal-(Heating/Cooling Supply) • esidential Water Supply(single)
ft. ft in.1
I In dustrial/Commercial Residential Water Supply(shared) YB:GROUT::• _ :a:--.:•.;- :.
I hit ationI FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite, poured
Monitoring Recovery ft. ft.
lothermal
ction Well: ft ft
uifer Recharge r_'tGroundwaterRemediation
uifer Storage and Recovery ©i l Salinity B arrier ,FROM�/G TO TACK MATERIAL if a EMPLACEMENT METHOD
uifer Test E3Stormwater Drainage- ft ft
perimental Technology ,0Subsidence Control ft ft
othermal(Closed Loop) [ITracer ZO.DRILLING.I;OG'(attar]i`addition'slslieetsifrieces's T::, t•=s(Beating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION.(wlor,hardness,soil/rock type grain size etc)
0 .ft 6 a f` Bt�et nc C'1
4.Date Well(s)Completed: 2)--4^22 Well ID# I ft ft
Sa:Well Location: ft Z ft. i
0k PA las ft ft
Facility/Owner Name Facility lD#(if applicable) ft ft
sV50 gigkwaul 152 E leactat I AX ft ft
Physical Address,City,andjip (' ft. ft 022
�...s.J41/X I. �1Z( .d` .-21:'RF.MARKS'.c.0�;:'�,:`'`:i"• -- `a:. _iiz`r'...:. =;_.�• _ -- -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C eati
3s.Sy, iy -N -�o.�G�z 4a W
6.Is(are)the wells) a—rient or Oi Temporary Signature o Cc Well Contractor Date
By sip ing 'form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 0,Yes or MN"— wio ISA NCAC 02C.0100 or ISA NCAC 6C:0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofthis record has beenprovided to thelwell 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface: Q. (ft) 24a. For All Wells: Submit this feim within 30 days of completion of well
For multiple wells,[ist all depths if different(example-3(200'and 2Q100D construction to the following.
10.Static watet level below top of casing:qd (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 m, �.
( ) 24b.Fok Infection Wells: In addition to sending the form to the address in 24a
{ above,also submit one copy of this forur within 30 days of completion of well
12.Well construction method: Lp construction to the following:
(i.e.auger,rotary,cable,directpush,etc.) t
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,iRaleigh,NC 27699-1636
13a.Yield(gpm) - Method of test: air pressure 24c.For Water Suuuly&Infection Wells: In addition to sending the form to
LL� the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: (/�r/l &Nf Amount: 9(i completion of well construction to the county health department of the county
where constructed-
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources i Revised2-22-2016
• I .