GW1-2022-08501_Well Construction - GW1_20220906

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only:
1.Well Contractor Information:
14:.WATER ZONES r ;
Well Con ct rName FROM TO DESCRIPTION
ft ft. .
bps ft ft
NC Well Contractor Certification Number
15:O_=R.CASING,(fo-r mnl&* sea w611s)OL2I7N>Et Ctfa
Morgan Well &Pump, Inc. FROM TO' DIAMETER TIDCKYESS MATERIAL.
Company Name +1 ft ft r,1/81 in, sd,21 pvc
..i^ 16 Il�ER CASING OR•TIIBII�G.' eotfierrual cIo'sed loo' t '''' =t'
2.Well Construction Permit#f: .. 2A O FROM TO DIAhSTER TffiCIST'ESs .`:•;MATERIAL' ^
List all applicable well construction permits'(ie WC,County,State,Parlance,etc.)- ft. ft in.
3.Well Use(check well use):
ft ft in.
Water Supply Well: 17--SCREEN,::.: :: �_ =.`_•. :(:'rl:.•:• :.:r;,.:_::`.;:- r.' ::.. .::'•'
FROM TO DIAMETER SLOT SIZE THICKNFSS MATERIAL.
Agricultural MMunicipal/Public n ft in.
:Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) ft ft �•
I TnduslxiaUCommercial J Residential Water Supply(shared) :_:r,.- ...•:;•=. . - -
[Aqiffr
'0n FROM TO MATERIAL - EM£LACEM.NT METHOD&AMOUNT
ater Supply Well: 0 ft 20 ft. bentonite• poured
oring Recovery ft ft.
n.WeIl,
er Recharge r-f Groundwater Remediationft fter 5tomage and Recovery SalinityBamer FROO MATTM­ ENiPLACEIVEiT iYIIOD
er Test Stormwater Drainage ft ftmental Technology Subsidence Control ft ft
ermal(Closed Loop) QlTracerrmal(Heating/Cooling Return) J Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,h�ardUness,Lsoilirock type grain s'ae etc)
t
!�2 z ft ft i Ll f i�•C
4.Date Well(s)Completed. ) 12Z- Well 1D#/ ft ft.
'-7
o 't 9
,1}52.Well Location: ,p R
1_.R7.+� L/1 V 1... ft ft S D
_r 67 2022
Facility/Owner Name Facility ID#(if applicable) ft ft
13 a 17; !J, ?i�A! bLy C ZMS
ft ft r,�„,;. :_, ,: ..•. .. j r;;l
Ph sical Address,City,and Zip ft ft
S :ZI:"RF.MARK.4:�.:.=i,:-%-:J:. :;• _ _ - --- _ _
County Parcel Identification No.(PIN) `
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
15.SG L(o N�520' .S32 W ate'
6.Is(are)the well(s)*Permanent or ©ITemporary Si ofCe ell Contractor D e
B W.3 'g this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: W Yes or LI No with I5A NCAC 02C.0100 or 15,4 NCAC 02C..0200 Well Construction Standards and that a
Ifthis is a repair fill out known well cansb•ucfion information and explain the notate afthe copy ofthls record has beenprovided to the well owner.
repair under 421 remarla•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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: goo (ft-) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells list all depths i rdifferent(ixample-3(C200'and 2@100D construction to the following:
10.Static water level belowtop 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.Borehole diameter: 6 (in.) 24b.For Injection Wells- In addition to sending the form to the address in 24a
t above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: L1 construction to the following:
Cie.auger,rotary,cable,dsectpush,etc.) -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYrW71LS ONLY. 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a.Yield(gpm) • v Method of test• air pressure 24a For Water Supply&Iniection Wells: In addition to sending the form to
�1_n �j the address(es) 'above, also submit one copy of this form within 30 days of
13b.Disinfection type. Amount: .fib l3Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016