GW1-2022-05656_Well Construction - GW1_20220610

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only,
1.Well Contractor Information:
14:.WATER ZONES (:.
Well Contra or Name FROM TO DESCRIPTION
ft ft I
J,51� �A ft ft
NC Well Contractor Certification Number l
15;OVTER;CASING,(&o mniti=casea*ills)O�A1JNER —2 'livable';
Morgan Well &Pump, Inc. FROM I ft. TO' DIAMETER TMCIaMSS MATERIAL,
Company Name +1 ft 61/8/ in• sdr21 pvc
P Y t
1GINNER CAS]TT OR•TIIBIIVG.' eotliermal cto'sed rod` "='�'
2.Well Construction Permit#:_ �/° �/ l FROM To I DIAMETER THICKNESS (, MA'rt''RTAT.
List all applicable well constr-uctionpermits'ri.e.UIC,Cowgg State,Ymiance,a c.)• ft. ft in.
3.Well Use(check well use): ft ft in.
VG
upply Well 17_"SCREEl\'..:.: t _ - ,>>. -
f!E
TO DIAMETER SLOT SIZE •THICKNESS ivIATERIAL
ltural 0Muaicipal/Public ft
rmal(Heating/Cooling Supply) 19iResidential Water Supply(single) ft ftial/Commercial Residential Water Supply(shared) ___,. ,,.•: _
:'hri ati0n FROM I To I,MATERIAL I EMPLACEMENT METHOD&_4MOUNT
Non-Water Supply Well: kSA�/G
20 ft '
bentanite- poured
'Monitoring Recovery ft.
Injection Well:
ft
Aquifer Recharge Groundwater Remediation
RAVEL'PACK if a`licibl '
Aquifer Storage and Recovery Salinity Barrier TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C3Stormwater Drainage ftI Experimental TechnologySubsidence Control ft
Geothermal(Closed Loop) Tracer :ZO.DRILLRQG.LOG'(itticli`additiinii4slieedifaeces's- l::t' :=, --
i Geothermal(Heating Coolie Return) FROM TO DESCRIPTION(colo rdness,soil/rock type in size,etc)
g ) �Other(explain under#21 Remarks) O ft 0 ft (P`.V"'�
4.Date Well(s)Completed: ` / Well IIN �Q. ft-
t LAO ". 1i
5a.Well Location: Q ft L4 ft ra Q 9 4 .
ft
R
Facility/Owner Name Facility ID#(' ap ca le) R- ft
c� ft ft
Physical Address,City,and Zip ft ft
'22iRRMARTCC:_
County Parcel Identification NA.(PIN) i`s 4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) J� '22.Ce tioII' 1
N
IrlfOr�ytalte� ?�iOti wut Ft4i J
6.Is(are)the well(SAPermanent or OTemporary S W ature of Certifed Well Contractor Date
By 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 Io.-• with ISA NCAC 02C.0100 or JSA NCAC!42C.0200 Well Construction Standards and that a
Ifthis is a repair fr11 out known well construction i4forrhation the nature of the copy of this 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: t1 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O 24a. For All Wells: Submit this form within 30 dayg of completion of well
For multiple wells list a depths if dierent(example-3(200'and 2@100� construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
I•'water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 'r o"N
above,also submit one copy of this form within 30 days of completion of well
i
(ie,auger,rotary,cable,directpuslT,etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) o 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: aA � 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 22 2016
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