GW1-2022-06380_Well Construction - GW1_20220608

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. Contractor Information:
C •14:.VyATER ZONES•:•. -
WellContractorName FROM TO I DESCRIPTION
V ft 1q ft I
1 J�y 4
ft ft f
NC Well Contactor Certification Number
15:OIIZ'ER:CASING•,fortnnlli eased wells OEtTT ?.R ifa"livable ;`.:.::'
Morgan Well &Pump, Inc. FROM TO DIAMETER THIciews MATERIAL
Company Name SO-T6
+1 R- 6i161 ' sd21 pvc 16"IINIl�R CASING OR�TIIBIIYG`(�•eottiermal•clo'sed-loo' .'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permiis'rz.e.07C,County,State Ymionce,eta) ft ft in.
3.Well Use(check well use): ft ft' in
Water Supply Well: 17.SCREEN', ,:.; `::. .`�< `:•:. :.:;:,:. ::-;..: ,::=.::. >.:' :;.:. ..::° .-:
FROM TO DIAMETER SLOT SIZE THTCKNWS MATERIAL
Agricultural i Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft � ft in.
dustriaUCommercial Residential Water Supply(shared) :18:GROUT::.. -
�..
hri ation FROM TO MATERIAL - EWI CE1rIFNTMETHOD&-SMOUNT
Non-Water Supply Well: 0 ft 20 ft bentonite' poured
s Monitoring Recovery ft. ft.
Injection Well: ft ft
_Aquifer Recharge )Groundwater Remediation
Aquifer Storage and Recovery �ISalinityBamer MND/GRTp LPACKMA�RTAT.e EMPLACEMENT METHOD
_•Aquifer Test QlStormwatea Drainage- ft ft
i Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer :20.DRIIJaNG.L'OG'(ktticli addition'sl sheetsif recess"kl::
I Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock typ rain size etc)
�f ft ft �r
4.Date Well(s)Completed" Well ID# Ib ft i
5a.Well Location: / Oft ft .
P,l�/1tS ��M ����CL li��fiSCU ft ft. I&el ej grei.
Facility/Owner Name Facility M#(if applicable) ft ft
Physical Address,City,and Zip ft
All g6ZZ9�6`I 19 -�.
County T—� Parcel Identification No.(PIN) J
5b.Latitude and longitude in de.orees/minutes/Seconds or decimal degrees: ,
(if well field,one lat/long sufficient)is suffici [}•`�
„ � 22.Certification:
.N TO, 9q Z3q W a Z 2v2Z�
6.Is(are)the well(s)o
permanent or ©f(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: QI Yes orCoNo with I5ANCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair fiR out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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: - '�- 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 fist all depths ifdiflerent(example-3 tci 20 ridd 2@100) construction to the following.
10.Static water level below top of casing: ��`-� (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe 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: f-O" L' construction to the following:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPIrX LLS-ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I ! .
13a.Yield(gpm) Method of test: air pressure 24c.For Water Supply&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: �+ Amount: �b� completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016