GW1-2022-03814_Well Construction - GW1_20220404

WELL CONSTRUCTION RECORD (GW 1) For Intemal Use Only:
I.Well Contractor Information:
� •14:.WATER ZONES;', �'•• � !:.:•,
We Con actor Name FROM TO�� AESCR)PTiON ~
ft.
ft ft I
NC Well Contractor Certification Number 1
15.OUTER,CASWG,(fo'r multi=rasedwelLs)0 2LIlyER(ifa'licabie)'J
Morgan Well&Pump, Inc. FROM TO' DIAMETER THI7.66.
S MATERIAL
Company Name +1 ft ft 61/8/ ' in. sd,2 pvc
ei 16`INNEIt CASING O)3•TUBING.''eotIiermal clo
2.Well Construction Permit#: i�l W J^® FROM TO DIAMETER THICISNESS MATERAAL
List all applicable well construction permits r,e.UI,Cowity,Slate,Variance,etc)- ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: IVSCREEN', __ _ -
i � FROM TO-- DrAMETER',•I SLOT SIZE .~THICM4ESS 14fATERL.L
Agricultural !_tMuaicipal/Public ft ft. fn.�
i Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
I Ilidustrial/Commercial PP y( g ) ft ft in:
J�Residential Water Supply(shared) 718:GROUT::
i IIIi atiOn FROM TO :.,M.4TERI'AI, ~. EMPL.4CF.MENTMETHOD&.--nJINT
Non-Water Supply WeII: 0 ft 20 ft• hentonite.. poured
'Monitoring Recovery ft. ft
Injection Well:
Recharge �-y ft ft
Aquiferg DGroundwaterRemediation
Aquifer Storage and Recovery ::19:SAND/GRA
A VEL'PACI�if a"licilile - ::_':; :',•=,
q g ry OSalinityBarrier FROM TO MATERIAL : EMPLACEMENTrI METHOD
Aquifer Test 13stormwater Drainage ft ft.
1 Experimental Technology 0 Subsidence Control ft ft
Geothermal(Closed Loop) QlTracer :20.DRILLING.LOG'(it tiiWidditidikQ slieetUfi e6e-sa-); �'•t:,i
Geothermal(Heating/Cooling Return) -i Other(explain under#21 Remarks) FROM •TO�j DESCCR'IPTION(color,hard ess,soiUrock type grain srse etc)
4.Date Well(s)Completed: Z_ Well m# ft q,0 ftJff/o,../
SJa'^WeIILocAa^iicn: �' /y ft r ft. < U'�l
ft,
ft
Facility/Owner Name FacAty ID#(if applicable) ft ft
r-- r (e�q COA?, . � ft
Physical Address,City,and Zip ft ft i.
(-)4
County Parcel Identification No.(P1N) MY
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' 4�
(ifwell field,one lat/long is sufficient)
22.Certification:,]
6.Is(are)the well(s) Permanent or oTemporary e of Certiti ltyeIlr g or Date
By signing this firm,I her•ebv certify that'the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Mell Construction Standards and that a
Ifihis is a repair fill out known well construction information and explain the natw-e oflhe copy ofthia record has beery 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
NUM]3ER:of wells construction details. You may also attach additional pages ifnecessary.
drilled: .22o
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ (ft•) 24a. For All WeIIs: Submit this form•within 30 days of completion of well
For multiple welLr list all depths if d�erent(erarnple-3 er 00'ar:d 2@I00) ,
construction to the following.
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 Cenfer,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Infection WeIIs: In addition to sending the form to the address in 24a
12.Well construction method: o r L� above,also submit one copy of this form within 30 days of completion of well
i foll th t o e following:
I(ie,auger;rotary,cable,directpush,etc.) construction
Division of Water Resources,Underground Injection.Control Program,
EWATERUPPLX WELLS ONLX: 1636 Mail Service Center Raleigh,NC27699-1636
Method of test: art pressure24c.For Water SuuDly&Iniection Wells: In addition to sending the form to
Q the addresses) 'above, also submit one copy of this form within 30 days of
type: G f Amount: / 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