GW1-2022-05653_Well Construction - GW1_20220610

kip r "AN
WELL'. CONSTRUCTION RECORD (GW-1) For Internal Use Only:
ti
1.Well
lContractor Information: 14:
FROM
MATER ZOONES,,'. RiPTlON ~
Well Contra orAC Name
ft
r! r/` ft
{J�SL? 4 ft ft
NC ell Contractor Certification Number I5:OIITER CASING,(foc multi=casedlwells Oft r, .0(if a
Morgan Well &Pump, Inc. FROM TO DIAMETER TMCENMS MArRRre=.
Company Name s +1 ft- S ft- 6 val 1 in' sd,21 pvc
p y 2.Well Construction Permit#• �•®'] 16:INNER CASIIdG OR•TQBIIVG. •edtliei�malclo'sed-loo` � `='_' :•:
t(Hy (� [ � FROM TO DraMETER THICEN SS MATFRTdT.
List all applicable well construction permits'(Le.07C,Countv,State,Variance,etc-)- ft ft in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN'.:-'.: '::. .`�: .:•: --I-7F.:'.. .::
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural Municipal/Public ft ft- in.
RResidential
Geothermal(Heating/Cooling Supply) Water Supply(single) ft ft in.
I Industrial/Cominercial DResidential Water Supply(shared) ,rib:GROAT:?." '- ' "'"' _"``""'"`'' - "
loi atlOn I FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
'monitoring DRecovery ft M
I1"
jection Well: ft ft
'Aquifer Recharge n Groundwater Remediation . _ . . ,
::19:SAND/GRAVEL'P9 CK if a'livabler.
Barrier Storage and Recovery Salinity Baer FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater'Drainage ft ftExperimental Technology QlSubsidence Controlft ftoop)Geothermal(Closed L OTracer :20.DRILLING.LOG'(attiiY dditiun'sl slieed f neces's--j':�;Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type in size,etc.)
CE) ft O ft. &, f
4.Date Well(s)Completed: J� Well ID# Tin it.
o ff• r"0,/1//�,
5a.Well Location:, :5 ft 0 ft- %n/J), nxit
j �c'� f° �a fl- S lU�
Facility/Owner Name Facility M#(if applicable) ft ft
I! KeU �i�S��/hr� cn � ft ft h�.. K�
Physical ddress,City ft ft
;✓l Cc71�1 MARxs=,
County Farce Identification No.(PIN)
In�ixar; �� farm �9
5b.Latitude and longitude in de.arees/miuutes/seconds or decimal degrees: to t
(if well field,one lat/long is sufficient) (�I .Q 7 /
C.J L ' ,� (> /� 22 C ' cation:
35. N. W
6.Is(are)the well(s)NPermanent or 13Temporary SignVre of Certified Well Con or Date
By signing this form,I hereby certify that the we1Z(s) was(were)constructed in accordance
7.Is this a repair to an existing well: MYes or ANo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out brown well construction information and explain the nature of the copy ofthii record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm
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 depth below land surface: 300 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 t@200'and 2Q100) construction to the following.
10.Static water level below top of casing: V A) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this!form within 30 days of completion of well
12.Well construction method: CO r L` construction to the following:
(Le.auger,rotary,cable,directpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) - Method of test: air pressure 24c.For Water Supply&Iniectioir Wells: In addition to sending the form to
/n o L the address(es) 'above, also submit lone copy of this form within 30 days of
13b.Disinfection type: C 1ar117L Amount: r G 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