GW1-2022-06374_Well Construction - GW1_20220608

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well�Contractor Informaltlion:QCfel+ CIQV-SCi •14:.6dATERZONES
Well Contractor Name TO DESCRIPTION
✓�O A- ft ft
— ft ft i
NC Well Contractor Certification Number
15;OUTER;CASING,(fnc multi=caged wells)OR JMJE (ifa licable's
Morgan Well&Pump, Inc. FROM ITO' DIAMETER TMCMWSS MATERTAi.
Company Name +1 ft' ft' 6 1181 m' sd,21 pvc
2.Wen Construction Permit#:
061
�`� 16:TAII`IER CASING OIt•TIIBII�G:'•eoth'ermalcio'sed-3o6' � -'•_' :•:
I FROM TO DIAMETER I THMENESS MA'rE TAL
List all applicable well construction permits'r e.UIC,County,State,Variance,etc-), ft ft. in.
3.Well Use(check well use): ft• ft. in.
Water Supply Well: I. 11-SCREEN', ,'..:::'::. . :;.•"::.:. .`,,._;,: :.; .
FROM TO DIAMETER SLOT SIZE THTCKNESS MATERIAL
Agricultural Ei MunicipWPublic ft ft. in.
Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) ft ft in.
I Industrial/Commercial Residential Water Supply(shared ;18:GROUT::. -
•I -i lion FROM TO MATERIAL Y E vel-i MENT METHOD&AMOUNT
Non-Water Supply Well: o M 20 ft. bentanite• poured
Monitoring Recovery ft. ft
J.Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation r.
Aquifer Storage and Recovery nSalinityBarrier FROM TO MATERIAL I EMPLACEMENT METHOD
i Aquifer Test r3Stormwater Drainage ft ft
i Experimental Technology Subsidence Control ft ft.
i Geothermal(Closed Loop) Tracer :20.7DRITI�TG.I OG"(attarli'addition'slsheetsifaecess -j':{ =s ''�
1 Geothermal(Heating/Cooling Return) J Other(explain under#21 �) FROM To D CRIP ION(wlor,hardn soil rock type grain s ze etc)
ft ft •(
4.Date Well(s)Completed: Well ID# D R I U f. �I-"l
Sa.Well Location: •v ft �ft' y�Ljrt
tCiN4� O -p ' 1 75 ft ft
Facatty/Owner Name �`_v OFac
ility]D#(ifapplicable) ft ft
/ Le
Physical Address,City,and Zip ft. ft.
��rtf✓'�S r2I612EMARISS'?.' :�.' `:i} _ ?,14�i�i.-,' - -
county PamelIdentificationNo.(PIN) lnftN� t31 fv .R.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if ell fi Id,one lat/long is sufficient)
*�// 22.Certification:LI7�6 "N ��.6�Z7S W
6.Is(are)the wells) Permanent or [ (Temporary Siwature of Certified Well Contractor Date
�GGG°"' _��� By signing this form_[hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or*No No with I5.4 NCAC 02C.0100 or 15A NCAC 01C,0200 Well Construction Standards and that a
Ifthis is a repair,fi11 out known well construction information and erplain the naiw•e of the copy ofthis record has been provided to the well ow�ter.
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
constriction,only 1 GW-1 is needed. Indicate TOTAL NUMBER bf wells construction details. You may also attach additional pages if necessary.
drilled:_ �j ^\ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓ ty —(ft) 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'mtd 1(a3100) 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.BorehoIe diameter: 6 (in.) 24b.For Iniection Wells: In additionto sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: C Q� L( construction to the following:
(le.auger,rotary,cable,d rectpush,etc.)
Division of Water Resources,Underground Injection Control Program,
E13b.Disinfection
SUPPLY LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
f Method of test: air pressure 24c.For Water Supply&Iniection Wells: In addition to sending the form to
r� the address(es) 'above, also submit one copy of this form within 30 days of
type: �C-U01 Gf Amount: � 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
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