GW1-2022-05804_Well Construction - GW1_20220609

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WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
I.Well Contractor Information:
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•14:.FPATER ZONES,,',
Well Contractor Name FROM TO DESCRIPTION
\ ft
ys�So- ft
ft
NC Well Contractor Certification Number
15:OUTER: SING,(fa"r multi=lased wells)O�2L�ER ifa'litahle)'
Morgan Well&Pump, Inc. FROM T DIANDZTER THICK.`IEssI MATMUAL
SIS111
+1 61/8I Ln sdY11 pvcs
Company Name
16 IlVI�R CASING OR•TUBING 'eutliermal r1o'sed l06".'
2.Well Construction Permit#: FROM TO DTdMRTTfR THICKNESS •+ MATRRTAL
List all applicable well construction permits'rL e.UIC,Colony,State,Variance,etc� fL ft m.
3.Well Use(check well use): ft. ft. im
Water Supply Well: 17__-SCREEN'.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural OMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared) ,;I8:GROUT: -
'Ilri ation FROM TO MATERIAL MalACEMENTMETHOD&AMOUNT
Non-Water Supply Well: o ft 0 nS fL bentonite 4wr.& rvfh P
Monitoring Recovery ft ft.
Injection Well: ft ft
_ Aquifer Recharge 13GroundwaterRemediation
.19:SAND/GRAVEL-PACS rf ie'iichbre .'.•,:,. _ =-`
Aquifer Storage and Recovery �ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD'
i Aquifer TestStormwater Drainage ft ft
I Experimental Technology OSubsidence Control ft ft
Geotbermal(Closed Loop) OTracet :20.DRU IJNG.LOG'(atticli additiel it sheets,jf i eees''s -'':!,.'� =t
Geothermal eating Conlin Retum Other 74.
TO DESCRI TION(color,hardness,soillrock a Stu ete.)
(H g ) (explain under#21 arks)
ft. Jb ft Hr
4.Date Well(s)Completed• Well 1D# if, z, ft
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Sa.Well Location: - S O R a ft. (p Wti �4v •
ft ft- (AL friaA�
Facility/Owner Name �y,,� FacilityID�#(ifapplicable) a ft �Q
2 goo��i "l` �� \y) P4Gr,IGiliI ft ft.
Physical Address,City, ft ft
� and Zip e�� y -.S9. og 77
County Parcel Identification No-(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,oae lathono is s cient) 22.Certification:
6.Is(are)the well(s) Permanent or ©I(Temporary Signature of Cefitied Well Contractor Date
By siomino this form,I hereby ce7tiify that the well(s) was(were)constructed in accordance
7.Is this a repair to an eldsting well: ©Yes or 14J No with 15ANCAC 02C.0100 or ISr1 NCACi02C.0200 FYeH Conshvction SYgpd_rd
If this is a repairfill, out known well cansb action irformaiion and exp lain the nature ofthe copy of this record has been provided to the well owner. Gi{! T 5 a
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details: rA
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well siJ ta4-d,9w21022
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 111`tOP&��ts'O pFcc*cg'O�Unit
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9.Total well depth below land surface: UCH (t-) 24a. For All Wells: Submit this form within 30 dayS of completion of well
For multiple wells list all depths ifdOerent(example-3@200'and 1@100) construction to the following:
10.Static water level below top of casing:_ //-5— (ft) Division of Water Resources,Information Processing Unit,
If water level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.BorehoIe 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
Y L` construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
FFORRTER SUPPLX WW)LLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
(gpm) V Method of test: air pressure 24c.For Water Supply&Iniection!Wells: In addition to sending the form to
a the address(es) 'above, also submit one copy of this form within 30 days of
fection type: �C rt A qr Amount: `� 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 WaterResources •Q Revised 2-22 2016