GW1-2022-06373_Well Construction - GW1_20220608

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
1.Well Contractor Information:
ac{e+l C f(kQSe
14:.WATERZONES:'. ;' .•'...r:: .:''
Well Contractor Name FROM TO DESCRIPTION
ft ft
ft ft f
NC Well Contractor Certification Number
15:OUTER:CASINts,(fncmnlH-rasedw9ls)OR12(Q1R if'a'licable'
Morgan Well &Pump, Inc. FROM T DWOTER I TMCM4MS I MATERIAL
Company Name
+1 ft I bfo ft 6 1/81 f in' sdr2l pvc
18 3NNER CASING OI2•TQBING: eotfiermal'cln'sed lode
2.Well Construction Permit#: FROM TO DIAMTER THICKNESS MATERLAL
List all applicable well construction permits'r.e.WC,County,State,Variance,etc_r f, ft in..
3.Well Use(check well use): ft ft in.
WaterSupply Well: 1z SCREEN'.:
FROM TO DIAMETER SLOT SIZE TIirCKNESS MATERIAL.
ultural QMunicipal/Public ft ft in.
ermal(Iieating/Cooling Supply) Di Residential Water Supply(single) ft fttrial/Commercial Residential Water Supply(shared) :i18i GROUT-.'-..rq
tion FROM TO MATEMAL moi.4.CEmmThmHOD&AMOUNTater Supply Well: o ft 20 ft benionite poured
itoring Recovery ft. ft.
on Well:
�—,� ftfer Recharge t�Groundwater Remediation;, ':19:SAVD/GRAVEL'PACK rf a"licabl fer Storage and Recovery 'YSalinity Barrier FROM TO MATERTAI. EMPLACEMENTMETHODer Test OStormwater Drainage ftimental Technology Subsidence Control ft ft
ermal(Closed Loop) Tracer :20.7)RMJMG.LOG'(attiiH'idditfati'als'ets�•ueces's-�'=:; ;'-""ermal age
Return) J Other(explain under#21 ) FROM TO DESCRIPTION(rotor,hardness saillrock type grain s ze etc
/J / ft ft
4.Date Well(s)Completed: li� a Well ID# ft 11b ft
5 01Loccation: !��( / ft d ft S S ,
� OL) _,A ! ft it.
lb-0— t vu
FacgpgnnerrName Facility ID#(/if'applicable) ft ft
(Jt v� L(Kk-s�e4-- 1 CI t!, yid ft ft ,
Pbysi Address,City,and
ddress,City,and Zip
ft ft
�"l{��1.�'J�O/S :'21c l2FTyTdRTCR":.'i.';1;:-'•':i�'..::: _ - _ _
county+ J Parcel Identification No.(PIN) 'n `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certificaon•ti
N ��_ 66 IOZ W G qc e&ZL
6.Is(are)the well(s) Permanei t or ©i(Temporary Signature of Certified Well Contractor •Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Q Yes or'4I No with 15.4 NCAC 02C.0100 or ISA NCAC 02C.0200 FPell Construction Standards and that a
Ifthis is a repair,fill out(mown well construction information and explain the nature ofthe copy ofthis record has beertprovided to the well owmer.
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 bf wells construction details. You may also attach additional pages if necessary.
drilled:_ ' . 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i rdifferent(ex ple-3@200'and 2@100� construction to the following.
10.Static water level below top of casing: 0 A) Division of Water Resources,Information Processing Unit,
(twofer level is above casino 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: Y L� above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY PVELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a Yield(gpm) `� Method of test- air pressure 24c.For Water Supply&Injection'Wells: In addition to sending the form to
o� the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: �C-.ne>1 G Amount: qo 2+ completion of well construction to the`county health department of the county
where constructed
Form GW-1 North Carolina Department of Enviionmental Quality-Division of Water Resources Revised 2 22 2016