GW1-2022-05615_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
t i
Qse 14:.WATER ZONES,,'.
Well Contractor Name FROM T DESCRIPTION .
t J I5�O r ft.ft. f i
ft
NC Well Contractor Certification Number
.15;OUTER;Gt TG,(&j multi raseawP]ls)Q1ZLII�TEIt
Morgan Well&Pump, Inc. FROM TO DIAMETER TBICENMS MAT"IAL
+1 ft 3 ft 6 4GB. I in- sdY11 PvRs
Company Name � 1�;'�R SING OR•TIIBIIVG.'�eotfiermal-clo'sed-lo66V
2.Well Construction Permit 1}: FROM TO DIABSTER THICKNESS 11MATERIAL
List all applicable well constructionpermits'(ie U1C.Caativ,State,Variance,etc} ft ft in.
3.Well Use(check well use): it. ft uL
Water SupplyWeII: 17:SCREpN'-*-*. ::_:. .`�:' ='`: ::',:•i..:'�,::=:..,i.'n:;.. .:_:' . r
FROM TO DIAMETER I SLOT srZE I THLCKNESS MATERIAL .
Agricultural C514unicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) gi Residential Water Supply(single) ft. ft
I Tndustdal/Commercial E3Resideutial Water Supply(shared) .18:GROUT...t• ::
Irrigation FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring DRecovery ft. ft
Injection Well:
Aquifer Recharge Q Groundwater Remediation ft
19:SAND/D/GRAVEL'PACK Cf a'licabl'e
'Aquifer Storage and Recovery MSalinity Barrier FROM TO MATERIAL I EIY.PLACEMENT rYlMOD
I Aquifer Test QlStormwater Drainage ft ft
i Experimental Technology DSubsidence Control ft ft
Geothermal(Closed Loop) 13Tracer :26.DRII.LINGS OG(attacti'sdditian'sl s7i'eet3 recess -)": =s ''t'
Geothermal(Heating/Cooling Return) ril Other(explain under#21 arks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,et�
�f ft ft
Xkoj
4.Date Wells)Completed: ,'�-�y We1l M4 ft ft (u()"L lw
Sa Well Location / (j ft ft C„I - ' t 5 J
Farility/Ow'neerrName Facility ID4(if applicable) U ft U ft � 0, QUO;;
M 1ft. P a,,..
I Cl,�(ILS S / l OoC�jv l C �� ft �C� l�►l ¢o;ls��i`'= , G
Physical Address,City,and Zip / l ft. ft
��� j�/ �l
County Parcel Identification No.(PIN)
5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees:
lattlo(r�vVIV— e L p�is sufficient) V� (Fq I 22.Certification
f�JJ(( S t N W /!�u( oQ Zz-
6.Is(are)the wells) Permanent or ©I(Temporary Si- ature of Certified Well Contractor / ,Dat
kv signing this form,I hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or tyl No with ISA NCAC 02C.0100 or 15.4 NCAC,�01C.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 been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
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
conshuction,only 1 GW-1 is needed. Indicate TOTAL NUMBER'of wells construction details. You may also attach additional pages if necessary.
drilled:_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 600
( ) 24a. For All Wells: Submit this form within 30 day5 of completion of well
For multiple wells list all depths ifdifferent(example-3@200'andd 00D 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 casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) f 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method �� �L` above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL WE ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
- i _
13a_Yield(gpm) t Method of test: air pressure 14c.For Water Supply&Ini ectioni Wells: In addition to sending the form to
��yy 1 �1 the address(es) 'above, also submit one copy of this form within 30 days of
!
13b.Disinfection type: C rtnv1 qr- Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources •' Revised 2?2 2016