GW1-2022-08505_Well Construction - GW1_20220503

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only-
1. tractor I a"on:
•14:.WATER ZONES:'. :•
Well ConbAallgamc FROM TO I DESCRIPTION
ft ft.
NC Well Contractor Certification Number
� 'IS:OII;['ER-2ASINl:,(focmniti=riled-webs)O�£L•IlyEIt(ifa'licable's:-:[>.:':'-.`.=
Morgan Well &Pump, Inc. FROM I TO'
Company Name DIAMETER TEaCr�FSS MATERIAL
+1 ft. fr 11
61/s/ ! in' I sd21 pvc
3�1���� 16"7NNER C' G OR-TQI3ING k eotli fifial clo'sbd loo' : - - t::'
#
2.Well Construction Permit : (� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructonpermits'(ia UIC,Cowity,State,Variance,eta)- ft. ft In•
3.Well Use(check well use): fr' ft• rn'
Water Supply Well: 17:SCREEN'.:,:.: :•'•.:•:::_:,::: .• = . >. :. ..
l—;�1 FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL .
Agricultural l-tMunicipal/Public ft. ft in.
!Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft ft
1 Industrial/Commercial DResidential Water Supply(shared) :.`18:GROUT.':.•" ` "`:: ':
:Irrigation FROM TO MATERIAL - EMPLACEMENT METHOD&AMODNT
Non-Water Supply Well: 0 ft 20 ft bentonite poured
Monitoring ORecovery ft. ft
Injection Well: ft ft.
J Aquifer Recharge M'1Groundwater Remediation ::19.SAND/GRAVEL PACK if a"liable
Aquifer Storage and Recovery OSalinity Barrier FROM TO • MATERIAL EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage- ft ft
!Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer :7.0.DRiLLTNG.LOG'(attarli'additidn'alshee&,ifiiHes'sa");�;
Geothermal(Heating/Cooling etum) �Other(explain under#21 Remarks) FROM TO DESCRIPTION.(color,hardness,soil/rock type rain size,etc.)
/�Q /�� C
5 ft
4.Date Well(s)Completed !il !M Well ID# 0 ft
ft.5 WeIILocation• LA
ft. tFacilityM"gy�
acility ID (if app1lica''bl--e) ft
W 4
ft ft
sical Address,City,and Zip M6011
ft. ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fiel One Is is sufficient)N �'���� W 22 tion A
/12A
t
, �r'h�.r .u,3 2 22
6.Is(are)the well(s)*f Permanent or OTemporary Signa o Certi Well Contractor Dat
By this m,I herebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or INNo w' 5 MN AC 02C.0100 or ISA NCAC.02C:0200 Well Construction Standards and that a
If this is a repair fill out known well construction information and explain the nature of the copy ofthii 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 bf 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 list all depths if different(erainple-3(200'and 2@100D 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 addition to sending the form to the address in 24a
f.Well construction method: above,also submit one copy of this:form within 30 days of completion of well
(L r 0 r LI e.auger,rotary,cable,direct pusb,eta construction to the following:) -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test• air pressure 24c.For Water Supply&Iniectio n 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 typ : Amount: completion of well construction to &'county health department of the county
where constructed.
Form GW-1 Nortb Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016