GW1-2022-06070_Well Construction - GW1_20220701

Pinf:Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information:
_G aC cell C,i Q use, 14:.WA-TER ZONES
Well Contractor Name FROM TOJ DESCRIPTION
✓�®_ ft f
NC Well Contractor Certification Number
t 15.ODTER:CASING,(&o m wells
)s)0121 MP,(if-a"licib1e)'1
Morgan Well&Pump, Inc. - FROM I TO- I DW"=R THICIalEss MATERAALI.
Company Name �`
+1 ft. ft 61/8/ 1" sd21 pvc
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16:INIl�R CASIN 012•Tt7BING.'•edtfiermal•cIo'sed-lod'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATEPJAL
List all applicable well consttuctionpermits'(Le UIC,County,stale,YatiancA eta)• ft ft in.
3.Well Use(check well use): ft .ft in.
Water Supply Well: 17.-SCREEN',_:.: :;; .'�.-'•.:•= ::' ::.• ;:: :.:.:.:�.=r:;.:. .:= '
�1 FROM TO DIAMETER ES SLOT SIZE THrCKNS MATERIAL.
Agricultural D,hfuaicipal/Public ft ft
Geothermal(Heating/Cooling Supply) fl3t'Residential Water Supply(single) ft - - ft
I Industrial/Commercial E3Residential Water Supply(shared) ;;18:GROUT•::-- :; -- °` :•;_`
In'i ation FROM TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite poured
Monitoring Recover y ft ft
Injection Well: ft ft
_Aquifer Recharge of Groundwater Remediation
79:SAND/GRAVEL'YACK rf a"linable c..' ;:':.:._'.: .. r,`'.:•.:': ',. ':.
Aquifer Storage and Recovery (Salinity Barrier FROM TO MATE &L EWL LACEMFNT 1=10D
[lExperimental
uifer Test 0Stormwater Drainage ft ft.
Technology ISubsidence Control ft ft.
othermal(ClosedLoop) OTracer :20.DRII.LR�TG.L'OG-(at6iH2iddWiaAlsUets�iiHess"'•j':+-:thermal(Heating/CoolingReturn) Other(explain under#21 ) FROM TO DEs IPTI N(cot r,hardness,soil/rock type,grain size,etc)
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4.Date Well(s)Completed: Well ID# '.Oft Jft• AZ�n
5a.Well Location:
vft -7 ft st�
n �C11"�Grr� ft dC� ft
Facili WjwName j/ Facility ID# Ifapplicable) II f ft. '
ft ft.
6,1 Co
J x2
Physi alALIddress,City,and Zip ft ft
Gb(�rcUS
County Parcel Identification No.(Ply jjjL
5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) ;,1 r r f;0. =,ri-ig nit -
22.Certification: i:s
N W.
6.Is(are)the well(s) Permanent or QI'Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or j No with 15A NCAC 01C.0100 or ISA NCAC 02C.0200 MeH Construction Standards and that a
Iftlds is a repair,fill out known waD construction information and explain the nature afihe copy ofthii record has beenprovided to the well owner.
repair under 421 remarks section or on the back ofthisform 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: Z6 V (ft-) .24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(200'and 24t1'0�� construction to the following.
10.Static water level below top of casing: U (ft.) Division of Water Resources,Information Processing Unit,
Ifwafer level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
'y
12.Well construction method: % construction to the following:above, also submit one copy of this form within 30 days of completion of well
4� L`
(i.e.auger,rotary,cable,direct push,eta)Y—0•
[FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
3a.Yield(gpm) � Method of test• air pressure 24c.For Water Suuuly&Injection Wells: In addition to sending the farm to
the address(es) 'above, also submit one copy of this form within 30 days of
b.Disinfection type: C't/tc>�G C Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmenml Quality-Division of Water Resources Revised 2-.22 2016
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