GW1-2022-07305_Well Construction - GW1_20220809

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only. i
1.Well Contractor Information:
/� 'y 1 C f M"U� ' 14:FATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft ft
3S]a t ft
NC Well Contractor Certification Number
5:0 ING,(for multi-rasea oWjDS)OR LMJEA tfRDs-
Morgan Well &Pump, Inc. FROM TO' I DIAMETER THICHIVFSS MAnMrAi.
Company Name +1 ft ft 61/8/f �' sdt21 pvc
00 C G 16.�IIiER CAS�TG OR•TEMING:''eotfiermal
2.Well Construction Permit#: J - ( FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits'(z e.UIC,Cow4v,State, Variance,et)- it. ft in.
3.Well Use(check well use): ft in.
IVS
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE yTMCIOMS RMATERU.L.
Agricultural [DMuaicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Dr-idential Water Supply(single) ft ft in•
I Tndustn Commercial J Residential Water Supply(shared) 8A�•-• .. _ ._.•. _ -
;Irrigation FROM TO MATERIAL I ENOXACEMENTM=OD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft• bentonite poured
'Monitoring Recovery ft ft.
Injection Well:
Aquifer Recharge Groundwater Remediation ft ft
Aquifer Storage and Recovery Salinity Barrier 'iKoS�ND/G oVEL'PAC 1 MAC e EMPLACEMENT METHOD
1 Aquifer Test OStormwater Drainage ft ft
—Experimental Technology OISubsidence Control ft ft
Geothermal(Closed Loop) OITracer :20.DR -13NG.LOG'attaclisddition'sl 0l 6ed if
Geothermal(Heating/Cooliag Return) J Other(explain under#21 Remarks) FROM TO DESCRIPTION(colaT,hardness,soil/rock type in size,etc.)
R O �
4.Date Well(s)Completed: 1 IVY !Ir7T/ Well ID# Oft O ft
5a.Well Location: it ft c vV.A
ft ft ..
Facility/Owner a Facility ID#(if applicable) ft �"' '� s VP /
ft ft.
Physical Address,City,and Zip ft ft
0��� I���� .°Z1ERI'.MARKC`'::i:•:-�`�i-'- :, L#ERArt.3�2.Yl�(`;." ...�s
County Parcel Identification No.(PIN) D'•AJCli9vG
5b.Latitude and longitude in decrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
3S .3tG�k2� N - � 0, � SSS (o W 'i> I as
6.Is(are)the Wells) ermanent or Temporary Signature of CertiSM We ctor Date
2 y signing this form,I hereby certz,fy that thew (were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or,ga o with 15.4 NCAC 02C_0100 or lj.4 NCAC102C.0200 We17 Construction Standards and that a
If this is a repab•,full out known well construction information and explain the nature of the copy of this record has been provided to the well owmer.
repair under 411 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: 11 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: we (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiferent(example-3@200'and 1 a@100) construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
.Ifwoter 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: LI construction to the following-.
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS_ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) LA Method of test: air pressure 24c.For Water Supply&Iniection 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: completion of well construction to the county health deparhnent of the county
where constructed
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22-2016