GW1-2022-06231_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
G QcCe+i C 14'`ISe L14.AAXER ZONES-C. : -
: .....
Well Contractor Name FROM I
ATO` DESCRIPTION .
W5b A ft N ft.
NC Well Contractor Certification Number
15:OU CER:CASING,(fn"r multi=casea w6lls)OR T�•R(if a'licahle)' :?:'•;:'
Morgan Well&Pump, Inc. FROM TO" I DIAMETER THICKNESS MATERIAL
+1 ft, ft 61/81 in' sd,21 pvc
Company Name �O �� �\ r..j• +..:`•.
'vl 1ri:A�Il`IL+R C9SING OIt•T[7BIlVG.'•edtfier'rna7'clo'sed loo
2.Well Construction Permit#: FROM To DL4MRTA.R THICKNESS :N MATERIAL
List all applicable well co»shuctionpernz s'(ze UIC,C•oturiv,State,Variance,eta)• ft• ft m,
3.Well Use(check well use): ft. ft m•
Water Supply WeII: 17_-SCREEN',,:..:::!:;. . �:'•.:•':.: :'::.::. r,.- =:' .-:
FROM TO DIAMETER -SLOT SIZE •THICKNESS MATERIAL
I
Agricultural Municipal/Public ft ft in.
Geothermal(Heating/Cooliog Supply) *Residential Water Supply(single) ft ft in
I Industdal/CommercialE3Residential Water Supply(shared) :.:,•�.=,: ; . _ _ _
;iIS.GROUT•.*:•.
Fquifer
o FROM TO MATERIAL Y EMPLACEhMzTMETHOD&_&MOUNT
ter Supply Well: 0 ft 20 ft bentonite• poured
ring Recovery ft ft
Well: ft ft
r Recharge )Groundwater Remediation 79:SAND/GRAVET'PLiCK rf a'licalile ":;,. =':::r Storage and Recovery Salinity BarrierFROM TO MATERIAL EMPI ACEI47ENTMETHOD
r Test Stormwater Drainage ft ftental Technology OSubsideace Control ft. ft.
rmal(Closed Loop) OTracerrmal(Heating/Cooling Return) Other(explain under#21 y�5) FROM TO D CRIPTION(cola,hardness,soillrock type grain sin,etc)
Q
4.Date Well(s)Completed:.!_ Well 1D# ft a ft. t„7�
Sa.W oration: - ! ft. ft.
�iSeyic 2 ft ft «�
Facility/Ow a Facility #(ifapplicable) ft ft
q?g f?J fl-k G�l-k�le ft ft _ r t...,.
3 ,
ft. ft
Physical Address,City,and Zip "IT:RIATARKS
IT:RIMARucJUL V
County ' /r Parcel Identificatiioon No.(PIN)(
(lyii S:.w_1 :;••ter ng LlR7:
5b.Latitude
,and longitude in degrees/minutes/seconds or decimal degrees: lIP;
(rfwe}l-fig•-ne la t(1�°.ng„>s sufficrput) , 22.Certification-
N 71 ..
6.Is(are)the wel(s) Permanent or OTemporary Signature of Certified Well Contractor Date
lvvv����� By signing this farm,I hereby certrfy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or tNo with ISA NCAC 01C-0100 or ISA NCAC 01C.0100 Well Conshuction Standards and that a
If this is a repair,fill out brown well conch action information and explain tl:e naiur e of the copy of thik record has been provided to the well owner.
repair under#11 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: ' - I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erw ple-3@200'mrd 2VOOD
L(jam, construction to the following:
10.Static water level below top of casing: V A) Division of Water Resources,Information Processing Unit,
ywaler level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the fomr to the address in 24a
12.Well construction method: t-ar 0above,also submit one copy of this form within 30 days of completion of well(i.e.auger,rotary,cable,directpush,etc.) J
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
_ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.field(gpm) S-0 Method of test air pressure 24c.For Water Supply&Injection Wells: In addition to sending the form to
ry �{ the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: Gr- Amount: �I o2` 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