GW1-2022-06340_Well Construction - GW1_20220705

WELLUUNS"1RUCTIONRECORD (GW-1) For Internal Use Only:
L Well Contractor Information_ /} '
QC'CQ�� QU Se 14:.WATER ZONES
Well Contractor Name - FROM TO DESCRIPTION
14/ '�� ft. � ft
J`NO. ft ft
NC Well Contractor Certification Number
15:O'UXER C65Il�tTr,(fo"r Ih ORI (rfa"lirahIe)'U
Morgan Well &Pump, Inc. :• FROM TI DIAMETER THICEiIFSS MATERIAL
+1 ft ft 6118/ in. sd21 pvc
Company Name ���/� �, �p`
1��//,/vyvl 16:'INI�R Ce1Si7`IG OR•TIIB11�G.'•edthermal•do'sed-loo":,
2.Well Construction Permit#}: FROM To DIAMETER TmcmusS MATERIAL
List all applicable well construciionymnits'(r e. WC,Corarty State Ym3ance,etr_f ft. ft, in.
3.Well Use(check well use): ft. ft nr
f1A
r Supply Well: FROM TO DL1YfEfER SLOT SIZE THICIMMS MATERIAL.
cultural -i MunicipalRablic ft ft
thermal 2--
Geothermal Supply)' esidential Water Supply(single) ft ft
strial/Commercial DResidential Water Supply(shared) GRODT,:. .• __ _-;,• .....•,;..=,.:. - - -
hTi On FROM TO ,MATERIAL - EMPL-4CEMENTMETHOD&AMO=
Nan-Water Supply Wen: o ft 20 fL bentonite• poured
Monitoring ORecovery ft ft
Injection Well:
AquiferRecharge tGroundwaterRemediation ft
Aquifer Storage and Recovery Salim Barrier :.FR S9ND/GRAVELPACK tf a "licatile .•. •.:N `::• ::
q g ry �' ty FROM TO MATERIAL EMPLACEI�A'T METHOD
1 Aquifer Test QiStonnwater Drainage ft.' ft
!Experimental Technology DSubsideare Control ft ft
Geothermal(Closed Loop) DTracet :ZB.DItIGLIPIGS OG(atiach'sdditiorisI seets�(necess 7'.; :: f= ;'�:.'%
I Geothermal eatin�Coolie Retum _ other ) FROM TO DESCRIPTION(color,hardness saillrock type grairtsze etc)
(I3 �/ g ) (explain under#21
4.Date Well(s)Completed- Well ID# ft ft
Well L,oration• - I / Y ft. ft' 1'�•' f Gnu
Vt I
Facility/Owner Name im' + / Facility ID#(ifapplicable) ft
�3��1 �)G W�• g ��nw��� ft ft o n'�'.oJ[._F�•1'�'t� '
Physical Address City,and Zip •
��j��� � •mil 'z1:-aax'nrauua~ :�::- _- -_ - - - - - - -
countyE Parcel Identification No.(PIM
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: /� •
(ifwell field,one lat/long is sufficient)
/ (�/�/(..�Q� 22.Certification: a
N go .
l 10 l d giI �y�' 1 l �7'�t
6.Is(are)the well(s) Permanent or rI Temporary Signature of Certified Well Contractor •Date
By signing this form,I here-bv certify that the we11(s)was(were)constructed in accordance
7.Is this a repair to an existing welh QI Yes or° No with 15A NC.IC 020-0100 or 15A NCAC 02C,0200 Fell Construction Standards and that a
Ifilus is a repair ffl out brown well cansburtion information and explain the nature of the ropy gfMfi record has beerrprovided 10 the well owner.
repair under#l21 remark section or on Use back ofAiisform. • 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 N11 BER'of wells construction details. You may also attach additional pages ifnece-ssary.
drilled:_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '2vy (ft) 242- For All Wells: Submit this farm within 30 days of completion of well
For multiple wells list all depths(different(ezmnple-3 a 00'and2@100) construction to the following.
10.Static water level below top of casing: �V (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-I6I7
11,BorehoIe diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method r L� above, also submit one copy of this form within 30 days of completion of well
(ie,auge,rotary,cable,directpvsh,etc.) construction to the following. -
EWATRERUPPLY 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 Snpniy&Injection Wells. In additionto sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
type: C CtAof ar Amount: completion of well construction to the county health department of the county
where constructed-
Form GW-1 North Carolina DepatimentofEnvironmental Quality-Division ofWaterResources Revised2222016