GW1-2022-06246_Well Construction - GW1_20220701

WELL CONSTRUCTION RECORD (GW I) For Internal Use Only:
1.Wall Contractor Information:
QC{e ��4USe 14:.WrSTI NF.S;,
Well Contractor Name 0 T .DESCRIPTION .~
� ft ft
S 0"
ft ft
NC Well Contractor Certification Number
I5:ODTER,CASWG,(fi_r multi=risen•wells)09MKER(if-hp'licable)':;
Morgan Well&Pump, Inc. FROM T DLSMETER TBIQflVESS MATERLLL
Company Name �� 6 +1 ft, ft' fi 118/ m' sd,21 pvc
(�` 16`Il II�TER C 4S)1�TG OR T17SI2\TG:"eottiermal'cib'sed loo'
2.Well Construction Permit#: FROM TO DIAMETER THiCFi MS ... MATERML
List all applicable well constructtonpermitsr.e EUC,Couniv,State,Po lance,etc)- ft ft in,
3.Well Use(check well use): ft ft in
FTndustial/Co:mmerciral
upply Well: 17.-SCREEN',
FROM TO DrAME! R ^SLOT SrZE THICKNESS rMATERIAL-
ltural �MuaicipaLTublic ft yft in.
rmal atinCooling Supply). Residential Water Supply(single) ft ft in.
Residential Water Supply(shared)
Isi ation GROUT•:i• ..::;: .:.._•:,: _.:•,..:_..:. ..::,,::i:_,y:: :`-`''
FROM TO MATERTAL EMP ACEMENTh=OD&AMOIINT ,
Non-Water Supply Well: 0 ft 2p ft be- t nite• poured
Monitoring Recovery ft. ft
Injection Well:
ft ft
J AquiferRechergeI Groundwater Remediation
AquiferStorageandRecovery Salini Barrier '.19:SAND/GRAVEL�PACK rfa`licime ':.;_. :?:: :_': •..r; :?.': ;;?:
ty FROM TO MATERIAL EMPLACEMENT METHOD
_•G�eothermal
ifer Test ���:•Stormwater Drainage ft' ft
i erimental Technology Subsidence Control ft ft.
(ClosedLoop) OTracer :20.DRIGLa7GLOG'(attacli'sdditiorislslieetsafaecess ');i :•:=;
Geothermal(Fieating/Cooling Return) Other(explain under#21 ) FROM To nEse PTION color hardness,soillrock type,grain size,etc.)
i ft a
4.Date Wells)Completed: we ft L ft.
5a.Well;oration:: I. ft ft
3F\\ sic. D ft U ft (/ -V&
&FOwm rName Facility IDN(if applicable) ft `
I-cV
ft ft a 4_e.2 -i
Ph ,allf�Address,City,and Zip X'4 ft. ft I
�J`^��n ��• � �V \ '21:"iiFwreuuc=- - -:;•- _ - - - - �y -
county Cii:'«:D7 iC::24? l-tRg
Parcel Identification No.(PIN)
✓.dtelrS
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wen fpld,o e lat/long is suf5cient. f 22.Certification:
6.Is(are)the weR(s) Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerizfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©'Yes or l No with 15A NCAC 02C.0100 or 15A NCAC 02C%0100 Well Construction Standards and that a
If this is a re •Jill out known well construction information and esplain the nature ofthe copy ofthii retard has been provided to the well owner.
repair under*21 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: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fdifferent(example-3(200'a»d @100� construction to the following
1' Static water level below top casing: (ft) Division of Water Resources,Information Processing Unit,
IJwater level is above cositrg use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: 6 (in.) 246:For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
�� above, also submit one copy of this form within 30 days of completion of well
Q construction to the following:
(i.e,auge rota
, ry,cable,direct push,etc.) "
EDisinfection
UPPL WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
Method of test: air pressure 24c.For Water SuDDiy&Infection Wells: In addition to sending the form to
o� the address(es) 'above, also submit one copy of this form within 30 days of
type: A C�c�)G,, Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22 2016