GW1-2022-06238_Well Construction - GW1_20220701

WLLL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
I.Wen Contractor Information:
-
Well on�e, �� FROMATER ZOoNFS i'• � DESCRIPTION
fG ft
y�
ft ft
NC Well Contractor Certification Number
OU;CER:CASIN�.(fni•tiiulii_rasedwells)ORL•7I�TER(if_.licahle)' :=::'.:.::':".:
Morgan Well &Pump, Inc. FItoM To' DIAMETER TMCMNEss MATERIAL
Company Name
+1 ft -71 ft. 61/8/ in. sdr11 pvc
/�, '' II 16`RIUMR CASING OR•TIIBING. edtliermal cIo'sed 1od`
2.Well Construction Permit#:aw C.J�J J FROM TO DIAMETER TmclagEss •.nMA't'>..RTAT.,
List all applicable well constructionpermits'(te.UIC,Co-iv,State,patience,etc.), ft• ft in.
3.Well Use(check weIl use): ft ft in.
[lAgLicnItUral
r Supply Well: 17_SCREEN',:- =` •: :,:;:t::. �: ::-;,.: :.'::.;-- :•= ;..:::
FROM TO .DIAM= SLOT SIZE THICKNWS MATERIAL.
MMuaicipal/Public n fL
thermal(Iieating/Cooling Supply) Residential Water Supply(single) ft ft in.
s Commercial i Residential Water Supply(shared) IS:GROUT-.*+.. ';: _ - '":_%`'': - -
Irri anon FROM TO MATERIAL I EMPLACEMENTMET$OD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentonite. poured
Monitoring [JRacovery ft ft.
Injection Well:
__!Aquifer Recharge Groundwater Remediation ft ft F.
;'19:SAND/GRAVEL-PACIC if a"linable :-
Aquifer Storage and Recovery Salinity Barrier FROM TO - MATERIAL - MWLACEMENT i1=01)
_Aquifer Test OStormwater Drainage ft ft
I Experimental Technology Subsidence Control ft ft
i Geothermal(Closed Loop) E3Tracer :20.DRILLING.DOG'(atfacli'sddition'aI sheetsjd fiecess"')'';; '•=s -_
r Geothermal(Heating/Cooling Retain) r Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
ft. Q ft [ff
4.Date Well(s)Completed: 7 22 Well ID# ft ft•
Sa Well Location: 1 tt 10k1/­/\_
G ft S ft l ll�tr A,'4e�
Facility/OwrierName nFacility ID#(if applicable) ft. ft
ft ft
Physical Address,City,and Zip ft ft
�1•I W L� _ /C./ �3 ��/ R!MkRKS� - `:;•" C �..,,' ,?�'y,r: ,4'e^:p�`-,�'.;; _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,onelat/long is sufficient) 22.Certification: {Rw;TP.^.GCS i�i,^.0.^... � Ul;;y
35-Q�097 N_I.7,�S�'7 W D: JQ/c:0C-2t . 22
6.Is(are)the well(s)VPermanent or OTemporary Sim of Certified Well Co tractor -Date
,�, By signing this form,1 hereby certify that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or gr JNo with 15ANCAC 02C.0100 or 15,4 NCAC 02C,0200 Well Construction Standards and that a
Iffhis is a repair fill out known well construction information,/nd explain the nature of the copy ofthis 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 weII 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: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �� (ft-) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3 a200'and 2@100D
�0 construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
.Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
1, -�—/] �� above, also submit one copy of this form within 30 days of completion of well
O 4 "t construction to the following:
auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
E13b.Disinfection
UPPLY WELI_Q,ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test- air pressure 24c.For Water Suuuly&Iniection Wells: Ili addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
type: Amount: (p completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of water Resources Revised 2 22 2016