GW1-2022-06244_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Go ce+j CfQUSe 14:.WATERZONES;'.
Well Contractor Name FROM TO DESCRIPTION
14550_ Jft ft.
fit {t,
NC Well Contractor Certification Number
� '15:OU,CER-CASING,({o"r mnlfi=rased wells)OR L•7117EI2(if'a'licahIe' :'�::`.:.::'•`
Morgan Well &Pump, Inc. FROM TO I DIAMETER I TEEMMESS MATERIAL
Company Name +1 ft t 6 1181 in- sd21 pvc
qWb\-bq ol� Id Il�Il II R CeISIN O :-TIIBIIVG.'•etitliermal 616s6d_I1C'2.Well Construction permit#: FROM TO DIAMETER THICKNEss MATERIAL
List all licable well construction erm ft. ft. in.app p its'r.e.UIC,Cnarir;State,Ymiance,etc}
3.Well Use(check well use): ft• ft in.
Water Supply Well: 17_SCREEN', �< •=`:.: ::. ::;.: .- ::.:.
ETER SLOT SIZE TMCKNESS bIATERTAL.
J Agricultural Municipal/Public FROM ft. TO DIAM ft in.
Geothermal(Iieating/Cooling Supply)- J2esidential Water Supply(single) ft ft. in.
I Industrial/Commercial Residential Water Supply(shared) iI8rGROUT. - - -
-.''
Elni ation FROM TO MATERIAL EMPLACF.MENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft, bentonite• poured
Monitoring Recovery ft. ft.
Injection Well:
fit ft.
Aquifer Recharge )Groundwater Remediation r•. ,
,.-9:SAND/GRAVMPACK if a'ilcable
'Aquifer Storage and Recovery DSalinity Barrier FROM TO • MATERIAL '•EMPLACEIl7ENT rYIE'THOD
Aquifer Test Stororwater Drainage ft.' ft
J Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer :20.DRMILNG.IAG'(attach`idditionalile6.6ifiieces's""l::+:: '•:' `_
Geothermal(Heating/Cooliag Return) J Other(explain under#21 al1Gg) FROM TO DESCRIPT ON(calar,hardness,sailtrock type,grain size,etc)
ff C fL
4.Date Well(s)Completed: U��� Well ID# v ft. ft. `
Sad/WeIl Location: / ft• -6d ft. tJ
fit fit
Facilityne Name �Facility ID#(if applicable) ft ft. p T'C-1
ft. ft. +• n- +
Physical Address,City,and Zip ?6�afr- fit. ,J� IJ L O•f1=2`_ •:f.` -
11 w/� '2Zc•R'F.M6RTLC' � 'c•'u.. -�',.:'.
Init r: .(D1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in de.-rees/minutes/Secands or decimal degrees:
(ifwe]fine]at/lojn�s�sufficient) � 22 Certification' ..
.G//l ! •N W
•
6.Is(are)the well(s) IPermanent or Q'(Temporary Signature of Certified Well Contractor Date
V By signing this form,I hereby certify that the wells) was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or I No with 1SA NC,4C 02C-0100 or 1SA MCA 02C.0200 Fell Construction Standards and that a
Iftlds is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 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 TOTALNUIVMER'ofwells construction details. You may also attach additional pages ifnecessary.
drilled- ' i SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: gO® fft-) 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'g»d�100D construction to the following
) .
10.Static water level below top of casing: G `� (fit) Division of Water Resources,Information Processing Unit,
Ifwafer level is above casing;use"+" 1617 Mail Service Center,Raleigh,NC 27699-16I7
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
f above, also submit one copy of this form within 30 days of completion of well
�-•
12.Well construction method: 1 LI construction to the following:
(Le.auger,rotary,cable,direetpusI-4 etc.)
FOR WATER SUPPLY LS ONLY: Division of Water Resources,Underground Injection Control Program,
1636.Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air pressure 24c.For Water Sunniv&Iniecion Wells: In addition to sending the form to
n the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type:�0tAQ1 ax- Amount: Ly�— 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