GW1-2022-05819_Well Construction - GW1_20220609

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
I.Well Contractor Information:
use. 14.. A.TER ZONES
WellDESCRIPTION r
Well Contractor Name FWM
u
�SS�r ft ft
NC Well Contractor Certification Number
15:OUTER,Q9.SING,(&i multi caseawens)O,RTTntFR if'a
Morgan Well &Pump, Inc. FROM I DIAMETER THICKNESS MATERIAL
+1 ft V 6 ft a 1/a/ ' in' sd,21 pvc
Company Name f 16"MM C&SING OR TCJB7IVG.' entiiermal closed rod`
2.Well Construction Permit#: \J FROM To DIAMETER THICKNESS •j MATERIAL
List all applicable well construction permits'(r.e.UIC,County State,parlance,eta)- S. ft in.
3.Well Use(check well use): ft' ft' in.
Water Supply Well: 17.-SCREEN',::.. :°:::. . �: =. .:- .:'_•:'_. ::�. .r:;..'.:::' .
FROM TO I DIAMETER SLOT SrZE .THICKNESS MATERIAL.
Agricultural C]Municipal/Public fL ft in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft is
I IndustriallCommercial E3Residential Water Supply(shared) -
GROUT-.'..".:" _ _.,.�•,_ _.
i i,n ation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL bentonite poured
'•Monitoring DRecovery ft ft
Injection Well: ft ft
Aquifer Recharge t=1 Groundwater Remediation r.
•.19:SAND/GRAVEL'PA.CK rf a'licable •"'.C.. '=.::=:...._•.:•. •..i" '
'Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EM M PLACEMENT ETHOD
Aquifer Test 13Stormwater Drainage ft ft
I Experimental Technology Subsidence Control ft ft.
i Geothermal(Closed Loop) OTracer :ZO.DRIL.LING.LOG'(attacli`addition'sl s1i'eets�f uecess-')'':;''^'•`.' `-
FROM TO DESCRIPTION wlo,hardness,soil/rock e, . ' siu,etc)
1 Geothermal.(Heating/Cooliag Return) 0 Other(explain under#21 arks) O ft 07
�r
4.Date Well(s)Completed: '— Well ID# O ft- q"> ft V
IDA-
5 .WeIl Location:
`- 215r IL
ft ft
Facility/Owner Name
'(� 1 Facility ID#((ifapplicable) ft ft.
3 ` Yet �kV oocJ " D q 4)6A;a ft ft 4 w
ft. ft
Physical Address City,and Zip -
ko� f 7 Y3 Z1:3MMARKS'
County Parcelldend cation No.(PIN) nil
5b.Latitude and longitude in de.arees/minutes/Seconds or decimal degrees: DWOZOG
(if ell Id,one lat/long is sufficient) 22.Certification'
1901 N (1323 W M *IT-Z4rL
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified 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 l No with 15A NCi1C 02C.0100 or 15A NCAC 02C•.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction idformation and explain the nature ofthe copy ofthii record has been provided to the well owner.
repair under 421 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 N INMER'of wells construction details. You may also attach additional pages if necessary.
drilled 500
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form witbin 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200';70
00D construction to the following.
10.Static water level beIow top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwato level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
.Well construction method:
above, also submit one copy of this form within 30 days of completion of well
(L L� construction to the following:
(r.e,auger,rotary,cable,direct push,etc.) "
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
I
13a.Yield(gpm) ' Method of test: air pressure 24c.For Water SunDly&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: rt+►Q1 a r- Amount: 1 2 82 completion of well construction to the county health department of the county
z where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources •� Revised 2 22 2016
l ;