GW1-2022-05631_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information:
AOiCCC7 �QU�� .14:.WATERZONES,'.
Well Contractor
A FROM TO DESCRIPTION
qs- r J f t V\ ft
ft fL
NC Well Contractor Certification Number
15:OUTER,GASING,(idi multi-rased S'vells)OAt TTJF (if'a'licihle)'=;
Morgan Well&Pump, Inc. FROM TO'' DL43VOTER I TSICKtvMSS MATERIAL
+1 It,
` fL 1 6118/ in. sd,21 pvc
Company Name _�`
S o !d:•IIVNDR CASING ORTDBIlNG. •eotlier'mal,clo'sed-loti`
2.Well Construction Permit#. FROM TO DIAMETER TEICKNESs MATERIAL
List all applicable well construction permits'(f a UIC,County,State,Ymiance,etc f M ft- in.
3.Well Use(check well use): R ft m
Water Supply Well: I2:SCREEN'.:... '::. .' •.:._.,,,,.:... :.:• :•, ,;-..`_.,;,. ?.. .:;
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL.
-_Agricultural �Muaicipal/Public M fL in.
Geothermal(Heating/Cooling Supply) JIResideatial Water Supply(single) ft ft in-
I Industdal/Commercial E3Residential Water Supply(shared) 18:GROUT::."_' - -
a..
i iII ation I FROM TO MATERIAL - EMPLACEMENT METHOD&AMOIINT
Non-Water Supply Well: 0 ft. 20 ft. bentonite poured
rGeothermal
ring Recovery ft. ft.
Well: ft ft.
Recharge K3 Groundwater Remediation Storage and Recovery Salinity BarrieroTL EMPLACEMENT METHOD
Test OStormwater Drainage M 11ental Technology Subsidence Control ft ft.
mal(Closed Loop) TracerFROM TO DESCRIPTION(wior hardness,soillrock e, in size,etc.)
mal(Heating/Cooling Return) Other(explain under#21 arks) D
ft
4.Date Well(s)Completed: N Well ID# a, ft I ft
5a.Well Location: i 1' / ft. a ft'
Facility Qwner Name Facility M#(if applicable) 1 ft ft .ab
1 1c) 0 w �� {—Itt `1( ft ft ?—
Physical Address,City,and Zip ft. ft -~4
/Ae_cYLaaAh,_-,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(tf a eId,one lat/long is sufficient)
N go, /e �0 q 22.Certification:
Sir. `i1 O a Zak
6.Is(are)the well(s) A Permanent or OTernpoiary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)way(were)constructed in accordance
7.Is this a repair to an e3dsting well: L7'Yes or*No with 15.4 NC.4C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair Jill out known well construction information and explain the naim a of the copy of thii record has been provided to the well omier.
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: . 1 SUBMITTAL INSTRUCTIONS
9.Total well
jj depth below land surface: 1s (f-) Ma. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3(200'and 2@100D construction to the following.
10.Static water level below top of casing: (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 Iniection Wells: In addition to sending the form to the address in 24a
f above, also submit one copy of this fortis within 30 days of completion of well
12.Well construction method: r LI construction to the following.
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPP /X\WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) U Method of test air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: ct/►y�G r Amount: �01. 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