GW1-2022-08516_Well Construction - GW1_20220906

WELL CONST'RUMON RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information:
•14:,VPr1TER ZONES,.'. -
Well Contractor Name FROM TO DESCTION
�5`77-A tZS ft RIPz� ft
ft ft
NC Well Contractor Certification Number
'15:OIIZER,(.ASING,(for mnl@=rased wells)0 2I;II�TER(rfa'licahle)'-;:•:::....'•.'.=
Morgan Well&Pump, Inc. FROM TO' DIAMETER TtncMNiFss MATERIAL
Company Name +1 ft I log ft 6 1161 m' sd,21 pvc
�f *� / (� 2 16 DUMRCA-cUNG012•TUBING.'-eoth-a ma7•clds6d,-lod' 4:`:.;'''•_'
2.Well Construction Permit#: ��•�' l 1 9 c]q FROM TO DIAMETER THICKNE.sS MATERIAL
List all applicable well constructionpermits'(Le,WQ Cowtrv,State,Ymiance,etc-)• ft.
m
3.Well Use(check well use): •
ft ft in-
Water Supply Well: 17.'SGREEN'.:,:.. '::. .`�.. ..:•=•.:_ �; .::- ::.;:•.it.:�:;.:. ° .=:
� FROM TO DIAMETER SLOT SIZE TATCKNE.SS MATERIAL.
Agricultural ! t crpa]/Public ft ft in
Geothermal(Heating/Cooling Supply) Zesideatial Water Supply(single) ft : ft in•
17^ndustn�a]Commercial J Residential Water Supply(shared) �8.�0�.•. .. _ =_;,•,�.�..:..-=,.:. ...,;-- - _
:'hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 fL bentonite• poured
'•Monitoring ORecovery ft ft.
Injection Well: ft ft
Aquifer Recharge [2GroundwaterRemediation
:19:SAND/GRAVEL'PACK Cif a"IicablB ":.:::'_?:: -;:_':: . -.: .=':.'•.:: •'..
Aquifer Storage and Recovery MISalinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
_I Aquifer Test r3Stormwater Drainage ft ft
I Experimental Technology OSubsidence,Control ft ft
Geothermal(Closed Loop) EITracer :20.tiRILLING.I OG'(attacli'sdditional sheets fiecess -j'+; =.5
I Geothermal(Heating/CooIing Return) J Other(explain under#21 Remarks) FROOM TO DESCRIPTION(color,hardness,saiUroek type,grnin sae,etc)
v •ft.
Q ft 1
4.Date Well(s)Completed: Well ID# (/ ft. 0 o it
5a ell Location: ft ft i^c vl; e-
V7 ft ft ,{r
Facility/O erName tt (� Facility M#(ifapplicable) ft. f
225b ft ft L
Physical Address,City,and Zip ft ft
fZk12�16fARTIS`� - _ - -t;'•',}^ti'- _ - - _ -
County ParcelIdendficationNo.(PIN)
5b.Latitude and long tude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C do
5_ul b I -N 15L,0340 W
6.Is(are)the well(s) Permanent or DTemporary SigrAzJ0fCeAif2 Well ntractor Date
By signing this fo erebv certify that the we11(s) was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or with I5.4 NCAC 02C.0100 or 154 NCAC 02C,0200 Weff Construction Standards and that a
If this is a t•epair;fill ouf known well construction idfarmation a explain the natty a of the copy ofthii record has beenprovided to the weII owner.
repair under#21 remarks section or on the back of this form.
• 23.Site diagram or additional weII 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 my also attach additional pages if necessary.
drilled: i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 166 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: o (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27 699-1 61 7
11.Borehole diameter: 6 (in.) 24b.For Infection Welli• In addition to sending the form to the address in 24a
12.Well construction method r t L� above,also submit one copy of this form within 30 days of completion of well
construction to the following-
(i.e.auger,rotary,cable,directpuslr,etc.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSG�JNLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) t7 d 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
113b.Disinfection type: YiA Amount: 66z completion of well construction to the county health department of the county
where constructed_
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 222 2016