GW1-2022-06242_Well Construction - GW1_20220701

VVELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
T (� ,
OA A C1 1 14:. A TER ZONM
Wel ont=6Name FROM TO DESCRIPTION
L� /� ft ft
- J G�A ft ft
NC Well Contractor Certification Number
15:OUTER.CAS]NG,(fo'rmulti=niiseawellc)ORTR(ifa'livable)';:::`.:.;:' `•_
Morgan Well&Pump, Inc. : FROM TO. THICKNESS THICKNESS MATERIAL
Company Name +1 ft ft 6 ilal in. sd21 pvc
CS
f n 16.Il-II�R C G OR•TIIBING.' eotfierma7 closed loo' `" r
2.Well Construction Permit4: (/�, W 21 ( L FROM TO DIAMETER THICKNESS .:., MATERIAL
List all applicable well co nstnucdon permits'(i e.UIC,—Coufliv,Stale,Ya tan ce,etc.) it ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN',: ''•`:-:: :�: '.:=-;..:'_,:':::• r,.
� FROM TO DIAMETER SLOT SIZE THICKNESS 14IATERiAL.
Agricultural L_tMuaicipal/Public ft. it. in.
!Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft ft in•
Industn`al/Commercial I Residential Water Supply(shared) -
:18:GROUT.
I Inn ation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite• poured
Monitoring DRecovery ft. ft
Injection WRell:
Aquifer echarge Groundwater Remediation ft ft
-19:Aquifer Storage and Recovery 0Salinity Barrier :FROSMAND/GRTO . PA
' CK , R7AT e EIYOLACEMENT,IY=OD
2.LAquifert Q Stormwater Drainage ft ft.
al Technology !Ol Subsidence Control ft ft(Closed Loop) ITracer :ZO.tiRTLLII�TGDOG'(aftac]i5idditiori'slssfieefiecess(Heating/Cooling Return) _I Other(explain under#21 Remarks) FROM TO DESCRIPTION(valor,hardnes,saiUrock type grain sae ere)
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IL
i
4.Date Well(s)Completed: _1 ` Lt- Well ID# 1 ft O ft-
buh
5a.Well Location: .� ft ft �(b n . . -
e Y w/, c ft ft I big
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FacilityrName Kl Facility ID#(if applicable) ft ft
1 ft ft �`'' E x ., sm °¢
1 'v. r...�z,..�6,..:...a �#rt li--- ' }.
Physical^Addd=s,City,and Zip ft ft
qqG
Co`unty Parcel Identification No.(PIN)
5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees: `� 'OG
(if well field,one latflong is sufficient) Q 22.;tlficaiion:
SJ �? • ��� N V i.�LpI.1 W 5-'J
6.Is(are)the well(s) IPermanent or OTemporary Si a ofCe ed WA ContralZr Date
\ By signing this form,I hereby cerdfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an esdsting well: QYes or No with ISANCAC 02C.0700 or 15A NCAC 02C,0200 9W1 Construction Standards and that a
If this is a repair fill out known well conshuction information a explain the nature of the 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 NUIvIBER'of wells construction details. You may also attach additional pages if necessary.
drilled:. t1 SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: JO® U) 24a. For All WeHs: Submit this form within 30 days of completion of well
Formultiple wells list all depths 1fdi erent(example-/3(200'and 2@100) 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
t above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: � LI construction to the following:
(ie_auger,rotary,cable,directpust�etc.)
EWATERUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test air pressure 24c.For Water Suppiv&Iniection Wells: In addition to sending the form to
,,nn ^'► the addresses) 'above, also submit one copy of this foal within"30 days of
type: 6,LCJ�i �i Amount: / �� completion of well construction to the county health department'of the county
where constructed.
Form GW-1 North Carolina Department ofEnviromnental Quality-Division of Water Resources Revised 2 22-2016