GW1-2022-05628_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
C fC C l 4lISe 14:.WATER ZONES:', r : is_ ':..•r ::''
FROM TO DESCRLPTIO14
Well Contractor Name � ft 4 ft I
WsSo- A-
ft � �
NC Well Contractor Certification Numbet
IS:OU7'ER:CASING,(&i multi=rasda w6I1s)OR LII� aR if 'll -;cible'
Morgan Well& Pump, Inc. FROM TO' DIAMETER THICKNESS MATERIAL
AL
ft 61- ft• 61/81 ! in.
Company Name ///��� sd21 Pvo
f_ 1 /'� L 16:IINIDIER CAMNG OR '•TVBING. eotli&bial closed lod":
2.Well Construction Permit#: o 1 �J J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructionpermits'(xe.UIC,Coumv,State,Variance,etc.)- ft• ft. m'
3.Well Use(check well use): R ft in.
Water Supply Wen: 17."SCREEN',>
F'ROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL .
Agricultural lMunicipal/Public ft ft in.
Geothermal(11 ating/Cooling Supply) RResidential Water Supply(single) ft
I Industrial/Commercial DResidential Water Supply(shared) :18:GROUT-.".
•.III7 from FROM TO ,MA.TERIAL -- I E1IPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
'.Monitoring DRecovery ft ft.
Injection Well:
Aquifer RechargeI Groundwater Remediation ft ft
.19:SAND/GRAVEL'PACK tf a'jicabre "'c>. : ': -
O
Aquifer Storage and Recovery OSallnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_i Aquifer Test E]Stormwater Drainage ft ft
NGeothermal
Experimental Technology Subsidence Control ft ftGeothermal(Closed Loop) Tracer(Heating/Cooling Return) J Other(explain under#21 a11CS) FROM TO DESCRIPTION(color,hardness,soillrock type,grain si etc)
ft b ft `r
-t8�21.
4.Date Well(s)Completed- Well ID# p ft D ft
Sa.WV 11 Location: / ft ft uNwt ok
ft o ft V` Gft
Facili/Owner Name Facility JD#(ifapplicable) ft ft
(�`^(.S'3 'C,r> e 1"' C�► )oa�e ft ft
Physical Address,City,and Zip 311 ft ft a
County V Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lona is sufficient) �11�0ISf�aLO1 f`
O�,p N go, 22.Certification: y .i 30G
- e,�� /laSy 19 &L L
6.Is(are)the well(s) 1Permanent or �,'1Temporary Signature of Certified Well Contractor Date
� `' By signing this form,I hereby ce;g5,that the wefl(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or*No with ISA NCAC 02C-0100 or ISA NCAC 02C.0200 Well Comhuction Standards and that a
Ifthis is a repair fnll out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well 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 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: I (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a 00' 2@100) construction to the following.
10.Static water level below top of casing: O (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
f above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: L( construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) J '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
air pressure 24c.For Water Suppy&Iniection[Wells: In addition to sending 13a.Yield(gpm) �� Method of test: i l g the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: C rtnc-A G,. Amount: 16'L 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 Revised 2 22 2016