GW1-2022-05651_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: /y
7 QC CQ7-I' 14 V Se 14:.WATER ZONES,,'. : ' f I:_ {: :r';.,. •' i
Well Contractor Name FROM TO DESCRIPTIO
` N
✓�O_ S ft ft IVV
IL ft I'
NC Well Contactor Certification Number
'15:O G,(for multi-rased•webs)OR Luij (if hcable'-t;
Morgan Well&Pump, Inc. FROM TO' DIAMETER THICMIMS MATERIAi.
Company Name +1 ft 6 11B/ in. sd21 pvc
C. / r���� FROM ER CASING OIi•TIIBIIVG. T eot]iermal closed-
FROM loss
2.Well Construction Permit#: W TO DL9METER THICKNESS MATERIAL
List all applicable well construction perm us'(La UIC,Cowrie State,Vaj!an ce etc.)* ft ft in.
3.Well Use(check well use): ft ft in.
17 SCR
Water Supply Well: EEN', _-:.::.i ::_:,.: :::.._�.- ::.. .:=`•` .-.
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL.
Agricultural DM al/Pablic, ft ft in.
Geothermal(Heating/Cooling Supply)' esidential Water Supply(single) ft ft
I Industrial/Commercial E3Resideatial Water Supply(shared) :i18,Q20IIT
:'ln1 ation FROM TO .•MATERIAL.�. EM2I.4CEMENTMETHOD&_SMOIINr
Non-Water Supply Well: 0 ft 20 ft bentonite. poured
Monitoring DRecovery ft ft
Injection Well:
�—,� ft ft
Aquifer Recharge �Groundwater Remediation
•.19:SgND/GRAVEL'PACK(if a�licabI-e .. •`• -. --'- `..-
'Aquifer Storage and Recovery OSalinity Barrier I FROM TO MATERIAL EMPLACEMENTio=OD
Aquifer Test DStormwater Drainage ft ft
i Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer :20..MRMTMiG.LOG'(attacli=additioiial s1•ieets
Geothermal(Heating/Cooling Return) i Other(explain under#21 ) FROM TO DESCRIPTION(mlo,hardness,soillrmk type,grain size,etc
J c
n r� ` .ft ft fb.�Jn
4.Date Well(s)Completed:J'S .l,G Well ID# ft ft a
Sa.Well Location: / ft ft
T6n �e rkn ft ft
Facility/Owner Name ft ft.
j' Facility ID#(ifapplicable)
L/5e22 -TGr k n e�_ ,h G ft ft
—7
Physical Address,City,and Zip / ft ft
�/% �+'rll
County Parcel Identification No.(Ply
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Una
(ifwell field,one lat/long suffi
cient) 22.Certification:
-N - Sl. W
6.Is(are)the well(s) Permanent orOi Temporary Signature of Certified Well Contractor Date
By suing this form,I hereby certify that the we (s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or*No No with 15A NCAC 02C.0100 or 15A NCAC 02C,0200 Y7el7 Consbuction Standards and that a
lfthis is a repair fill out)mown well construction information and explain the naiw•e of the copy ofthii 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 bf wells construction details. You may also attach additional pages if necessary.
dulled SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 66 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'aw11Q100) construction to the following.
10.Static water level below top of casing: Z (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) t 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12 Well construction method Y L► above, also submit one copy of this'form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,directpuslr,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
//L� 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) t10 Method of test: air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
�y e the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type:_J C qAQ1 G r' Amount: JfJZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 2 22 2016
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