GW1-2022-06375_Well Construction - GW1_20220608

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
L r i
7 QC CQTj C 4 Vse, •14:.WATER ZONES:', - i 1 :•':.
Well Contractor Name FROM TO DESCRIPTION
ft ft
✓So ft ft-
NC Well Contractor Certification Number
15;OT==R;CASING,(fnr multi=rased wells)012 LIIZER tf a'licahle)'a :
Morgan Well&Pump, Inc. FROM TO' DIAMETER THIcxiQFss MATERIAL
Company Name f +1 ft ft- 6 1/8l i in- sd,21 pvc
I V 1GII R CASING OR TIJBiNa. 'eotbermal closed-rod`: -'�'
2.Well Construction Permit#: FROM To DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(e VIC,CowgK State,Variance,etc_J ft• ft. m'
3.Well Use(check well use): ft' ft• in.
Water Supply Well: 17 SCREEN',' :f::. .` J' ;.:_:.c;::.•.• '.::_',, <::ir,.:_::.. .::; -:
NROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural CiMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) 12fResidential Water Supply(single)
ft ft
I Industrial/Commercial E3Residential Water Supply(shared) .18.,GROUT.:; :: - '•;"- : ::r.:,:- -
E Im i ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft• bentonite poured
Monitoring 0Re..very ft ft.
Injection Well: ft ft
_I Aquifer Recharge �1 Cnoundwater Remediation
A uifer Storage and Recover Salinity `�' �/GRAVEL PACK if a•licable "..::=;: :•. .. r• •
q g y tyBa?rier FROM TO • MATERIAL
EMPLACEMENT'METHOD
PAquifer Test QlStorrawater Drainage ft ft
NGeothermal
Experimental Technology [3Subsidence Control ft ftGeothermal(Closed Loop) Tracer(Heating/Cooling Return) 0 Other(explain under#21 FROM TO DESCRIION(color,hardness,soil/rock type,grain;Eetc)arks) b ft ft C
t
4.Date Well(s)Completed: v Well ID# ft• tij;0 ft
Sa.Well Location: / eLo ft. t ft fbus (L
gf)A— 1)� ft. ft 5��
Facility/Owner Name Facility ID#(if applicable) , ft
ft Yv ft v
Pbys' Address,City,and 'p V ft. ft
CA
21c722MARKS=:.':':':,:-:1
County Parcel Identification No.(PIN) LJ0
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
OG
(ifwell field,one Iat/long is sufficient) 22.Certification'
N . 6 SZU� W
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
vvvvYY������ By signing this form,I herebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or*No No with I5A NCAC 02C.0100 or 15A NCAC,:02C:0200 Well Construction Standards and that a
IJThis it a repair fill out known well construction information and explain the natw•e of the copy of this record 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. 1 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 trdifferent(example-3Q200'arV
0�
construction to the following:
g.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1,Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to 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: CO. L` construction to the following:
(i.e.auger,rotary,cable,directpush,etc.)
FOR WATER SUPPLY WELLS 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 SuppI,&Injection Wells: In addition to sending the form to
the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type: j C'tAU1 qr Amount: bti completion of well construction to th'e 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